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 A
Explanation
Choice A rationale
Painless, bright red vaginal bleeding at 36 weeks gestation is a classic sign of placenta previa, where the placenta is abnormally implanted in the lower uterine segment, covering the cervix, and causing bleeding without pain.
Choice B rationale
Threatened abortion is characterized by vaginal bleeding before 20 weeks of gestation with or without abdominal pain. At 36 weeks, the term would be inappropriate, and the symptoms do not match.
Choice C rationale
Abruptio placentae involves painful vaginal bleeding due to premature placental separation. The presence of pain differentiates it from placenta previa.
Choice D rationale
Preterm labor may present with contractions, cervical changes, and possible bleeding, but the key feature distinguishing it from placenta previa is the presence of uterine contractions and pain, which are absent in this scenario.
Correct Answer is B
Explanation
Choice A rationale
Cervical dilation is a source of visceral pain during labor due to the stretching and opening of the cervix, and it is not incorrect information.
Choice B rationale
Stretching of the pelvic muscles is incorrect because visceral pain during labor is typically associated with internal organs and not the stretching of pelvic muscles, which is more somatic pain.
Choice C rationale
Nerve stimulation is a cause of visceral pain as labor pain is transmitted through the nerves to the spinal cord and brain.
Choice D rationale
Uterine contractions are a major source of visceral pain during labor as they involve the powerful and rhythmic tightening and relaxing of the uterine muscles.
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