A nurse is conducting an initial assessment of a newborn delivered with a nuchal cord. What clinical findings should the nurse anticipate?
Facial petechiae
Erythema toxicum
Periauricular papillomas
Telangiectatic nevi
The Correct Answer is A
Choice A rationale
Facial petechiae are small, pinpoint, red or purple spots on the skin that can occur when a newborn has a nuchal cord, or the umbilical cord wrapped around the neck. This is due to the pressure exerted on the baby’s face and neck during delivery.
Choice B rationale
Erythema toxicum is a common rash seen in newborns, characterized by tiny bumps surrounded by red skin. However, it is not specifically associated with a nuchal cord.
Choice C rationale
Periauricular papillomas are small skin tags or pits seen near the ear. They are a common minor anomaly seen in newborns, but they are not associated with a nuchal cord.
Choice D rationale
Telangiectatic nevi, also known as “stork bites,” are common birthmarks seen in newborns, characterized by small, light pink patches, usually on the back of the neck. However, they are not associated with a nuchal cord.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Vaginal candidiasis is not a contraindication for the use of a suppository. Candidiasis is a fungal infection that can cause itching and discomfort in the vaginal area. While it may require treatment, it does not prevent the use of a suppository for constipation.
Choice B rationale
Afterpains are not a contraindication for the use of a suppository. Afterpains are cramping pains that some women experience after childbirth as the uterus contracts back to its pre- pregnancy size. While they can be uncomfortable, they do not prevent the use of a suppository for constipation.
Choice C rationale
A third-degree perineal laceration is a contraindication for the use of a suppository. A third- degree laceration extends through the vaginal wall, perineal skin, and perineal muscles to the anal sphincter. Inserting a suppository could potentially cause further damage or introduce bacteria into the healing wound.
Choice D rationale
Abdominal distention is not a contraindication for the use of a suppository. While abdominal distention can be uncomfortable, it does not prevent the use of a suppository for constipation.
Correct Answer is C
Explanation
Choice A rationale
Rust-stained urine is not a normal finding in a full-term newborn and should be reported to the provider. However, it is not typically assessed upon admission to the nursery.
Choice B rationale
Subconjunctival hemorrhage, or a small red or pink spot on the white of the eye, can occur due to the pressure changes during the birth process. It is a harmless condition that does not affect the baby’s vision and does not require treatment.
Choice C rationale
Single palmar creases, also known as “simian lines,” can be a normal variation in hand creases. However, they are also associated with certain genetic conditions, such as Down syndrome, and should be reported to the provider.
Choice D rationale
Transient circumoral cyanosis, or bluish color around the mouth, can be a normal finding in newborns when they are cold or after crying. However, if it persists, it could indicate a problem with the baby’s heart or lungs and should be reported to the provider.
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