A nurse is caring for four newborns.
Which of the following newborns should the nurse assess first?
A newborn who has subconjunctival hemorrhage of the left eye.
A newborn who has rust-stained urine.
A newborn who has nasal flaring.
A newborn who has overlapping suture lines.
The Correct Answer is C
Choice A rationale
Subconjunctival hemorrhage is a common, generally benign finding in newborns, often resulting from increased intraocular pressure during the birthing process, causing rupture of superficial capillaries in the sclera. It presents as a bright red patch under the conjunctiva and usually resolves spontaneously within a few weeks without intervention, thus it does not warrant immediate, priority assessment.
Choice B rationale
Rust-stained urine, or pink-tinged urine, in a newborn is typically due to the presence of uric acid crystals (urates) in the urine, a normal finding related to concentrated urine and the immaturity of the newborn kidney's ability to concentrate urine fully. This is a common, non-pathological observation in the first few days of life, indicating mild dehydration, but it is not an acute, high-priority concern.
Choice C rationale
Nasal flaring is a significant sign of respiratory distress in a newborn, indicating the infant is attempting to increase the diameter of the nasal passages to decrease airway resistance and enhance the intake of oxygen. This compensatory mechanism suggests compromised gas exchange and potential hypoxemia, requiring immediate assessment and intervention to prevent further respiratory compromise.
Choice D rationale
Overlapping suture lines, also known as molding, occurs when the cranial bones shift and overlap during passage through the narrow birth canal. This is a normal, expected finding, especially after a vaginal delivery, and the shape of the head typically returns to normal within a few days to a week, posing no immediate threat to the newborn.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A speculum exam to test for fetal fibronectin is primarily used to predict the risk of preterm labor in symptomatic women between 22 and 34 weeks of gestation. Since the client is at 37 weeks of gestation (term) and the concern is a slow trickle of fluid suggesting rupture of membranes (ROM), this test is not appropriate for the current clinical presentation or gestational age.
Choice B rationale
Nitrazine testing is a rapid, non-invasive method used to determine if the fluid leaking from the vagina is amniotic fluid. Amniotic fluid is alkaline (pH of 7.0 to 7.5) and will turn the yellow-to-orange nitrazine paper to a characteristic deep blue color, which helps confirm the diagnosis of premature rupture of membranes (PROM), a likely cause of the reported fluid trickle.
Choice C rationale
A urinalysis determines components like protein, glucose, and ketones, and is mainly used to screen for conditions such as preeclampsia (indicated by proteinuria) or urinary tract infection (UTI). While part of routine prenatal care, it is not the diagnostic test for confirming ruptured membranes, which is the primary concern given the client's report of a slow trickle of vaginal fluid.
Choice D rationale
Amniocentesis is an invasive procedure used to aspirate amniotic fluid, typically to assess fetal lung maturity (L/S ratio) or for genetic testing. Since the client is at 37 weeks and the suspicion is ruptured membranes, which warrants immediate action due to infection risk, the risks and benefits of an amniocentesis for lung maturity are not justified.
Correct Answer is C
Explanation
Choice A rationale
Avoiding the preschooler's presence at prenatal visits can inadvertently promote feelings of exclusion and resentment, suggesting the new sibling is an unwelcome disruption. In contrast, involving the older child in the pregnancy experience, like listening to the fetal heartbeat, helps normalize the upcoming change and prepares them for the new family dynamic, fostering a positive adjustment. This inclusion is crucial for emotional security.
Choice B rationale
Making a significant change, such as moving the preschooler from a crib to a bed, immediately before or the day the new baby arrives, associates the loss of their comfortable sleeping arrangement with the sibling's arrival. This can be viewed as a punishment, increasing stress and anxiety and potentially fueling sibling rivalry and regression. Major changes should be made several weeks before the birth.
Choice C rationale
Planning and dedicating specific, high-quality individual time ("special time") with the preschooler reassures them of their continued importance and secures their parent-child bond. This counteracts the potential feeling of being displaced or replaced by the newborn, which is critical for maintaining their self-esteem and emotional well-being during the family transition.
Choice D rationale
Insisting the initial encounter be a visual of the parent holding the baby can immediately trigger jealousy and a sense of loss of parental attention, as the parent is focused elsewhere. Instead, the parent should greet the preschooler first with open arms and allow the child to approach the baby on their own terms, promoting a gentler, more positive introduction.
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