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.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
Choice A rationale: While this is an important action, it is not the first priority immediately after delivery. The priority is to ensure the newborn's breathing and warmth.
Choice B rationale: Assessing the gestational age of the newborn is important but can be done after ensuring the newborn's immediate well-being.
Choice C rationale: This is important for proper identification, but it can be done after the newborn is stabilized.
Choice D rationale: The first action after delivery is to dry the newborn to prevent hypothermia and stimulate breathing. Drying the baby helps remove amniotic fluid and stimulates the baby's reflexes, making it the priority action.
Correct Answer is C
Explanation
Choice A rationale:
A gynaecoid pelvis is considered the most favorable pelvic shape for childbirth and is not a contributing cause of difficult, prolonged labor.
Choice B rationale:
A longitudinal fetal lie (baby's spine aligned with the mother's spine) is a normal and favorable presentation for birth and is not a contributing cause of difficult, prolonged labor.
Choice C rationale:
A persistent occiput posterior position (baby's head facing the mother's abdomen instead of her back) can be a contributing cause of difficult, prolonged labor and may lead to a severe backache for the mother.
Choice D rationale:
Fetal attitude in general flexion (baby's head flexed forward, chin to chest) is a normal and favorable presentation for birth and is not a contributing cause of difficult, prolonged labor.
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