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

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A rationale: If the woman does not desire future pregnancies, she may not need the MMR vaccine, but the timing of vaccine administration is not appropriate for the current situation.
Choice B rationale: Administering the MMR vaccine prior to discharge from the hospital after giving birth is recommended during the postpartum period, especially if the woman is planning to have more children in the future.
Choice C rationale: The MMR vaccine contains live attenuated viruses and is contraindicated during pregnancy. If a woman is planning to become pregnant and is not immune to rubella, she should receive the MMR vaccine at least one month before attempting pregnancy. This allows time for her body to develop immunity before conception occurs.
Choice D rationale: The current guidelines from the Centers for Disease Control and Prevention (CDC) advise that the measles, mumps, rubella (MMR) vaccine should not be administered during pregnancy due to possible effects on the uterus.

A. Scarf sign B. Arm recoil C. Moro reflex D. Heel to ear E. Popliteal angle

Correct Answer is ["A","B","C"]

Explanation

Choice A rationale: The Scarf sign assesses the range of motion of the newborn's shoulder and elbow joint. It measures the ability of the newborn's arm to be brought across the chest.
Choice B rationale: Arm recoil measures the degree of resistance and recoil of the newborn's arm when it is extended and then flexed against the chest. This reflex provides information about the newborn's muscle tone and neuromuscular maturity.
Choice C rationale: The Moro reflex, also known as the startle reflex, is elicited by a sudden change in the newborn's position or by a loud noise. It involves an initial extension and abduction of the arms, followed by a flexion and adduction. This reflex helps assess the newborn's neurologic and neuromuscular maturity.
Choice D rationale: "Heel to ear" is not a standard neuromuscular assessment used in the gestational age assessment. It may be an incorrect or unclear term.
Choice E rationale: The popliteal angle is not a neuromuscular assessment used in the gestational age assessment. It measures the angle of flexion in the knee joint and is not directly related to neuromuscular maturity

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about immunizations with a woman in her first trimester of pregnancy whose diagnostic testing indicates she does not have immunity to rubella. The nurse should recommend that the client receive a measles, mumps, rubella (MMR) vaccine at which of the following times?

Correct Answer is B

Explanation

A nurse is assisting in collecting data for a gestational age assessment on a newborn. Which of the following should the nurse check during a neuromuscular assessment? (Select all that apply.)

Correct Answer is ["A","B","C"]

Explanation

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