A nurse is performing an initial assessment of a newborn who was delivered vaginally at term with no complications.
Which of the following findings should alert the nurse to a potential problem?
Molding of the head
Acrocyanosis of hands and feet
Nasal flaring and grunting
Vernix caseosa on skin folds
The Correct Answer is C
The correct answer is choice C. Nasal flaring and grunting are signs of respiratory distress in a newborn and should alert the nurse to a potential problem.
The nurse should monitor the newborn’s respiratory rate, oxygen saturation, and chest movements, and notify the provider if the symptoms persist or worsen.
Choice A is wrong because molding of the head is a normal finding in a newborn who was delivered vaginally.
It is caused by the pressure of the birth canal on the skull bones and usually resolves within a few days.
Choice B is wrong because acrocyanosis of hands and feet is a normal finding in a newborn during the first 24 hours of life.
It is caused by poor peripheral circulation and does not indicate hypoxia or cyanosis.
Choice D is wrong because vernix caseosa on skin folds is a normal finding in a newborn.
It is a white, cheesy substance that protects the skin from amniotic fluid and helps with thermoregulation.
It usually disappears within a few days.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Document this as a normal finding.According to the American Academy of Family Physicians, bleeding from the dorsal slit after circumcision using a Gomco clamp is usually minimal and will stop once the clamp is in place.
Therefore, a small amount of blood on the diaper 12 hours after the procedure is not a cause for concern and does not require any intervention.
Choice A is wrong because applying gentle pressure to stop bleeding is not necessary and may cause more trauma to the wound.
Choice B is wrong because changing the diaper more frequently may also disturb the healing process and increase the risk of infection.Choice D is wrong because notifying the physician is not indicated unless there is excessive or persistent bleeding, signs of infection, or other complications.
Correct Answer is B
Explanation
The correct answer is choice B. Lactic acidosis.
Lamivudine (Epivir) is a nucleoside reverse transcriptase inhibitor (NRTI) used to treat chronic hepatitis B infection and HIV infection.
One of the rare but serious adverse effects of lamivudine is lactic acidosis, which is a condition where the blood becomes too acidic due to the accumulation of lactate.Lactic acidosis can cause symptoms such as nausea, vomiting, abdominal pain, muscle weakness, rapid breathing, and low blood pressure.
Choice A is wrong because pancreatitis is not a common side effect of lamivudine.
Pancreatitis is an inflammation of the pancreas that can cause severe abdominal pain, nausea, vomiting, and fever.Pancreatitis is more likely to occur with other NRTIs such as didanosine (Videx) or stavudine (Zerit).
Choice C is wrong because hypothyroidism is not a common side effect of lamivudine.
Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormones, which regulate the metabolism and energy levels of the body.
Hypothyroidism can cause symptoms such as fatigue, weight gain, cold intolerance, dry skin, hair loss, and depression.
Hypothyroidism is more likely to occur with other drugs that interfere with thyroid function such as amiodarone (Cordarone) or lithium
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