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
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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Related Questions
Correct Answer is D
Explanation
A. A bulging anterior fontanel suggests increased intracranial pressure, not dehydration.
B. Decreased urine specific gravity can occur with hydration or dilute urine, and it is not specific to dehydration.
C. Bounding pulses may be present in various conditions but are not a direct sign of dehydration.
D. Decreased skin turgor is a classic sign of dehydration in both infants and adults. It indicates a deficit of body fluids.
Correct Answer is C
Explanation
Choice A is incorrect because security tags are a vital part of hospital security protocols to prevent newborn abduction, and they should be worn at all times, even when the baby is in the room with the parent.
Choice B is incorrect as while it is important to have a list of authorized individuals, it does not directly prevent abduction; the staff still needs to verify each person's identity before allowing them to take the baby.
Choice C is correct because it demonstrates the client's understanding that all hospital staff should have proper identification, especially when they are involved in newborn care, which is a critical security measure.
Choice D is incorrect because having only one identification band is insufficient; multiple forms of identification for both the parent and the newborn are necessary to ensure the baby's safety and prevent any mix-up or abduction.
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