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 ["A","B","D","E"]
Explanation
Choice A rationale:
This statement indicates an understanding that a loose-fitting diaper will help prevent irritation and promote healing after circumcision.
Choice B rationale:
Applying petroleum jelly to the circumcision site helps keep the area moist and prevents the Plastibell from sticking to the penis during healing.
Choice C rationale:
While keeping the penis clean is essential, the use of soap is usually not recommended for the first few days after circumcision. Warm water and gentle patting are generally sufficient.
Choice D rationale:
Bleeding after circumcision should be reported to the doctor as it may indicate a complication that needs attention.
Choice E rationale:
The Plastibell device typically falls off on its own within a week after the circumcision procedure.
Correct Answer is C
Explanation
Choice A rationale: Placing elbow restraints is not a recommended practice for preterm newborns. Restraints are used in some cases to prevent the baby from pulling on tubes or lines, but it is not primarily for energy conservation.
Choice B rationale: While frequent position changes are important to prevent pressure ulcers and promote comfort, they may not necessarily help conserve energy in a preterm newborn.
Choice C rationale: Preterm newborns have limited energy reserves, and conserving energy is essential for their growth and development. Clustering care activities involves combining nursing care tasks to allow for longer periods of uninterrupted rest for the baby. This approach reduces the baby's energy expenditure and promotes better weight gain and stability.
Choice D rationale: While gentle touch and massage can be beneficial for preterm newborns to promote bonding and relaxation, it may not directly conserve energy as cluster care does.
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