A nurse is collecting data from a newborn who is 3 hr old. Which of the following findings should the nurse report to the provider?

Positive Moro reflex

Erythema toxicum

Acrocyanosis

Elevated bilirubin level

Answer and Explanation

The Correct Answer is D

A.   a positive Moro reflex, is a normal and expected finding in a newborn. It is not a cause for concern.
B.   erythema toxicum, is a benign rash that is common in newborns and does not require reporting to the provider.
C.   acrocyanosis, is a normal finding in newborns and is not typically a cause for concern.
D.   an elevated bilirubin level, can indicate jaundice, which may require treatment or further evaluation. This finding should be reported to the provider for appropriate management.

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Correct Answer is C

Explanation

A. Homans' sign is a test for deep vein thrombosis and is not a normal postpartum finding.
B. Full, firm breasts typically occur a few days after delivery when milk production begins, not at 20 hours postpartum.
C. A firm fundus at the midline is an expected finding in the immediate postpartum period, indicating that the uterus is contracting and involuting properly.
D. Lochia serosa (pinkish-brown discharge) is a normal finding around 3 to 10 days postpartum, but it is not typically present at 20 hours postpartum.

A. Administer the medication into the deltoid muscle. B. Check the mother's Rh factor prior to administration. C. Administer the medication 12 hr after birth. D. Administer the medication with a 25 gauge needle.

Correct Answer is D

Explanation

A: Administering the medication into the deltoid muscle is not recommended for newborns due to their underdeveloped muscle mass and the potential for injury. The vastus lateralis muscle in the thigh is the preferred site for intramuscular injections in infants.

B: Checking the mother's Rh factor is not directly related to the administration of phytonadione, which is given to prevent vitamin K deficiency bleeding in the newborn, a condition unrelated to the mother's Rh factor.

C: Administering the medication 12 hours after birth is not the standard practice. Phytonadione is typically given within the first hour after birth to ensure prompt prevention of hemorrhagic disease of the newborn.

D: Administering the medication with a 25 gauge needle is appropriate as it is small enough to cause minimal discomfort and large enough to ensure proper delivery of the medication into the infant's muscle tissue.

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A nurse is collecting data from a newborn who is 3 hr old. Which of the following findings should the nurse report to the provider?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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