A nurse is collecting data from a newborn. Which of the following anatomical landmarks should the nurse use to measure chest circumference?
Sternal notch.
Nipple line.
Lower ribcage border.
Axillae.
The Correct Answer is B
The nurse should use the lower ribcage border to measure chest circumference.
Choice A rationale:
The sternal notch is not an appropriate landmark for measuring chest circumference. It is a notch at the top of the sternum and not indicative of chest circumference.
Choice B rationale:
When measuring the chest circumference of a newborn, the correct anatomical landmark to use is the nipple line. This method ensures that the measurement is taken at a consistent and reproducible location across different individuals, providing an accurate assessment of the chest size relative to growth and development standards. It's important to position the measuring tape at the level of the nipples, encircling the chest at its largest point, which typically aligns with the nipple line.
Choice C rationale:
The lower ribcage border is also not suitable as it may vary significantly with respiratory movements and is not a stable landmark for consistent measurements.
Choice D rationale:
The axillae (armpits) are not used as a landmark for measuring chest circumference. It is not a standardized anatomical point for this purpose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
This response would not be appropriate because it provides incorrect information. Breast milk is already present in the mother's breasts during pregnancy, and the newborn's disinterest in eating is likely due to other factors.
Choice B rationale:
This is the best response because it acknowledges the mother's concern and offers a practical solution to help the newborn latch onto the breast properly. Correct latching is crucial for successful breastfeeding, and once the baby latches on correctly, they are more likely to breastfeed effectively.
Choice C rationale:
While it is true that newborns often experience deep sleep phases, attributing the disinterest in eating solely to deep sleep is not accurate. Offering support and guidance for breastfeeding would be more beneficial.
Choice D rationale:
This response oversimplifies the situation and may not address the actual reason for the newborn's disinterest in feeding. It is essential to help the mother with proper techniques rather than just waking up the baby.
Correct Answer is B
Explanation
Choice A rationale:
Pseudomenstration is a normal finding in newborn females due to the withdrawal of maternal hormones. It is not a cause for concern and typically resolves within a few days after birth.
Choice B rationale:
Positive Ortolan's test is a concerning finding in a newborn and indicates the possibility of developmental dysplasia of the hip (DDH). This test is used to check for hip instability, and a positive result may warrant further evaluation and intervention to prevent long-term hip problems.
Choice C rationale:
Dermal melanosis, also known as Mongolian spots, is a common benign condition in newborns with dark skin. It appears as blue or gray patches and typically fades within the first few years of life. While it may be alarming to parents, it is not a cause for immediate concern.
Choice D rationale:
Gynecomastia, the enlargement of breast tissue in male infants, is relatively common and is caused by the transfer of maternal hormones during pregnancy. It usually resolves on its own within a few weeks and does not pose a significant health risk.
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