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 C
Explanation
A. A weight gain of 16.4 to 20.5 kg (36 to 45 lb) is excessive for a client with a pre-pregnancy BMI of 21, which falls within the normal range. Such weight gain is more appropriate for an underweight client.
B. A weight gain of 5 to 7.7 kg (11 to 17 lb) is inadequate for a client with a normal pre-pregnancy BMI. This range is suitable for an overweight or obese client.
C. A pre-pregnancy BMI of 21 falls within the normal range (18.5–24.9), and the recommended weight gain for clients in this category is 11.4 to 15.9 kg (25 to 35 lb). This range supports healthy fetal growth and reduces the risk of complications.
D. A weight gain of 8.2 to 10.9 kg (18 to 24 lb) is slightly below the recommended range for a client with a normal BMI and may not adequately support fetal development. This range is more appropriate for overweight individuals.
Correct Answer is A
Explanation
A. At 12 weeks of gestation, the uterus has enlarged but is still mostly within the pelvis. Fetal heart tones are best auscultated over the suprapubic area using a Doppler, as the fundus has not yet risen to the level of the umbilicus.
B. The umbilical area corresponds approximately to 20 weeks gestation, so the fetal heart tones would not be audible there at 12 weeks.
C. Auscultating above the iliac crest would likely be too high at 12 weeks, as the uterus has not yet reached this level.
D. The area below the liver border on the right abdomen is too high for early gestation; fetal heart tones would not be reliably heard in this location at 12 weeks.
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