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:
Broccoli is not a reliable source of Vitamin B12. It is a good source of other nutrients like Vitamin C and fiber.
Choice B rationale:
Skim milk is a reliable source of Vitamin B12 and is often fortified with this essential vitamin.
Choice C rationale:
Figs are not a reliable source of Vitamin B12. They are a good source of fiber and certain minerals, but they do not contain Vitamin B12.
Choice D rationale:
Stewed tomatoes are not a reliable source of Vitamin B12. They are a good source of certain vitamins and minerals, but not Vitamin B12.
Correct Answer is B
Explanation
Choice A rationale: This response assumes that the couple's religious beliefs are relevant to them, which may not be the case. It is not appropriate for the nurse to suggest involving their minister without knowing their preferences or beliefs.
Choice B rationale: This response acknowledges the couple's emotional experience and shows empathy toward their grief. It offers support and reassurance that the nurse will be available to help them through this difficult time.
Choice C rationale: While this statement may be factually true, it is not empathetic or supportive of the couple's current emotional state. It may come across as dismissive of their feelings and minimize their grief.
Choice D rationale: While gathering information about the pregnancy is essential for the medical record, this question does not address the couple's emotional needs. It is more appropriate to focus on offering emotional support and assistance rather than immediately delving into clinical details.
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