A nurse is collecting data from a newborn who is 48-hr old. Which of the following findings should the nurse report to the provider?
Erythema toxicum
Mongolian spot
Telangiectatic nevi
jaundice skin and yellow tinge to the sclera
The Correct Answer is D
Choice A rationale; Erythema toxicum is a common rash that appears in many newborns and is not a cause for concern. It presents as small red bumps or pustules on the skin and usually resolves on its own without treatment.
Choice B rationale: A Mongolian spot is a birthmark that appears as a bluish-gray or bruise-like patch on the baby's skin, often on the back or buttocks. It is a benign condition and does not require any medical intervention.
Choice C rationale: Telangiectatic nevi, also known as "stork bites" or "angel kisses," are flat, pink, or red birthmarks that are common in newborns. They are usually found on the eyelids, forehead, and back of the neck. These birthmarks are harmless and typically fade over time without treatment.
Choice D rationale: Jaundice is a common condition in newborns and is caused by elevated levels of bilirubin in the blood. In most cases, mild jaundice is not harmful and resolves on its own. However, if the baby's skin and sclera (white part of the eyes) show significant yellowing, it may indicate a higher level of bilirubin, which can lead to complications if not properly managed. Therefore, the nurse should report this finding to the provider for further evaluation and appropriate treatment if necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Newborns who are small for gestational age (SGA) are not at risk of having decreased circulating red blood cells (RBCs).
Choice B rationale:
Blood glucose instability is a common finding in SGA newborns.
Choice C rationale:
Retinopathy is not typically associated with being small for gestational age in newborns.
Choice D rationale:
A well-rounded abdomen is not specifically associated with being small for gestational age. SGA newborns often have a smaller body size compared to their gestational age, and their abdomen may appear proportionally smaller.
Correct Answer is C
Explanation
Choice A rationale: The presence of phosphatidylglycerol (PG) in the amniotic fluid is another indicator of fetal lung maturity. The absence of PG is associated with an increased risk of respiratory distress syndrome (RDS) in the newborn.
Choice B rationale: A nonstress test is a test performed during pregnancy to evaluate the fetal heart rate in response to fetal movement. It is not directly related to assessing fetal lung maturity.
Choice C rationale: The L/S ratio is an important indicator of fetal lung maturity. Lecithin and sphingomyelin are two surfactants present in the lungs, and the ratio of these two substances increases as the fetal lungs mature. An L/S ratio of 2:1 or greater is considered an indication of lung maturity and suggests that the newborn should be able to breathe adequately after birth.
Choice D rationale: The biophysical profile (BPP) is a prenatal ultrasound assessment of the fetus, which includes evaluating fetal movements, breathing, heart rate, and amniotic fluid volume. While a BPP of 8 is a reassuring score, it does not provide direct information about fetal lung maturity.
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