A nurse is collecting data on a 1-day-old newborn.
Which of the following findings should the nurse identify as requiring follow-up?
A hymenal tag and white discharge on genitalia.
Edema on the scalp that crosses the suture line.
A heart murmur.
A large, deep sacral dimple above the gluteal cleft.
The Correct Answer is D
Choice A rationale
A hymenal tag and white discharge on the genitalia are normal findings in newborn females, often due to maternal hormone exposure.
Choice B rationale
Edema on the scalp that crosses suture lines, known as caput succedaneum, is common and typically resolves on its own without intervention.
Choice C rationale
A heart murmur in a newborn can be normal, as many murmurs are benign and resolve as the newborn's circulation adjusts post-birth.
Choice D rationale
A large, deep sacral dimple above the gluteal cleft can be an indication of underlying spinal abnormalities, such as spina bifida, and requires further evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
The client will be positioned in a prone position is incorrect because the prone position is not used for fetal anatomy ultrasounds.
Choice B rationale
The ultrasound will occur at 13 weeks of gestation is incorrect as the typical timing for a detailed fetal anatomy scan is around 18-22 weeks of gestation, not 13 weeks.
Choice C rationale
The ultrasound will be transvaginal is incorrect because at 20 weeks of gestation, a transabdominal ultrasound is more commonly used rather than a transvaginal one.
Choice D rationale
The client must have a full bladder is correct because a full bladder helps lift the uterus out of the pelvis, providing a clearer view during the ultrasound.
Correct Answer is D
Explanation
Choice A rationale
The hearing screening test is not related to brain development but specifically to the ability to hear sounds. It assesses the infant's auditory pathway from the ear to the brainstem to identify potential hearing loss early on.
Choice B rationale
This test does not assess for heart defects. Heart defects are usually detected through physical examination, pulse oximetry screening, or echocardiography, not through auditory tests.
Choice C rationale
Seizure disorders are diagnosed based on clinical presentation and electroencephalogram (EEG) results. The hearing screening test does not have any connection to identifying seizure disorders.
Choice D rationale
The primary purpose of the newborn hearing screening is to detect if the baby can hear various sounds, enabling early intervention if hearing loss is detected. Early identification and management are essential for speech and language development.
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