A nurse is collecting data from a newborn who was born 2 hr ago. Which of the following findings should the nurse report to the provider?
Overlapping suture lines
Acrocyanosis
Hypotonia
Blood glucose level 40 mg/dL
The Correct Answer is D
A) Incorrect- Overlapping suture lines in a newborn are common and usually resolve as the baby grows. This finding is not typically concerning.
B) Incorrect- Acrocyanosis, bluish discoloration of the hands and feet, is common in newborns and is a normal physiological response to adjusting to the outside environment.
C) Incorrect- Hypotonia, or decreased muscle tone, can be present in newborns and may improve over time. It's important to monitor but may not necessarily require immediate reporting.
D) Correct - A blood glucose level of 40 mg/dL in a newborn is considered low and requires intervention. Hypoglycemia in a newborn can have serious consequences and should be promptly addressed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is d. "I may develop discoloration on my cheeks from hormonal changes."
Choice a rationale:
- Statement:"I should expect to have burning when I urinate during the third trimester."
- Rationale:This statement is incorrect.Burning during urination is not a normal physiological change of pregnancy.It may be a sign of a urinary tract infection (UTI),which is a common infection during pregnancy.If a pregnant client experiences burning during urination,she should report it to her healthcare provider for evaluation and treatment.
Choice b rationale:
- Statement:"I may have an infection if I develop a dark line in the middle of my abdomen."
- Rationale:This statement is incorrect.A dark line in the middle of the abdomen,known as the linea nigra,is a normal physiological change of pregnancy.It is caused by hormonal changes that increase melanin production in the skin.The linea nigra typically appears in the second trimester and fades after delivery.
Choice c rationale:
- Statement:"I should expect my fingers and face to be swollen."
- Rationale:This statement is partially correct.Some swelling in the hands and face is common during pregnancy,especially in the third trimester.This is due to fluid retention caused by hormonal changes.However,excessive swelling,particularly in the hands and face,can be a sign of preeclampsia,a serious pregnancy complication.It's important to report any significant swelling to a healthcare provider.
Choice d rationale:
- Statement:"I may develop discoloration on my cheeks from hormonal changes."
- Rationale:This statement is correct.Hormonal changes during pregnancy can cause a variety of skin changes,including melasma,which is a brownish discoloration that often appears on the cheeks,forehead,and nose.Melasma is more common in women with darker skin tones and usually fades after delivery.
Correct Answer is A
Explanation
A) Correct - Monitoring for infection is an appropriate nursing intervention for a client whose membranes have ruptured, as there is an increased risk of infection after the amniotic sac has ruptured for an extended period.
B) Incorrect- Positioning the client supine is not generally recommended for a client in labor, especially if the client's membranes have ruptured.
C) Incorrect- Obtaining consent for a cesarean birth is not indicated solely based on the information provided.
D) Incorrect- Preparing for a forceps delivery is not indicated solely based on the information provided.
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