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:
Placing only part of the nipple in the baby's mouth may result in an ineffective latch, leading to breastfeeding difficulties.
Choice B rationale:
Placing the nipple and 2 to 3 cm of areolar tissue around the nipple into the baby’s mouth aids in adequately compressing the milk ducts. This placement decreases stress on the nipple and prevents cracking and soreness.
Choice C rationale:
Placing the entire areolar is not appropriate.
Choice D rationale:
While babies do have natural instincts to breastfeed, it is essential to provide the mother with specific guidance on achieving a proper latch to ensure successful breastfeeding.

A. "There's absolutely nothing for you to worry about. Newborns often breathe like this." B. "I'll sit here while you feed him and we'll check out his breathing." C. "You are going to be a very good, responsible mother to this baby." D. "All new mothers feel a bit anxious about things like this."

Correct Answer is B

Explanation

Choice A rationale: While it's true that newborns can have irregular breathing patterns, this response may come across as dismissive and not addressing the client's concerns.
Choice B rationale: The nurse should respond by actively listening to the client's concerns and offering to assess the newborn's breathing while they are feeding. Newborns can have irregular breathing patterns, including periods of rapid breathing (tachypnea) and pauses in breathing (periodic breathing). These patterns are generally normal and related to the baby's immature respiratory system adjusting to life outside the womb.
Choice C rationale: This response does not address the client's concern about the baby's breathing and instead focuses on the client's potential as a mother.
Choice D rationale: This response may minimize the client's concerns and does not address the baby's breathing issue. It's essential to acknowledge and assess the newborn's breathing pattern to ensure it is within the normal range.

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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 assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the baby's mouth, which of the following responses by the nurse is appropriate?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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