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. 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.
Correct Answer is A
Explanation
The correct answer is choice A.Washing hands before and after handling the cord stump can prevent the transmission of bacteria that can cause omphalitis, sepsis, and tetanus.
Choice B is wrong because applying petroleum jelly or ointment to the cord stump can delay its drying and increase the risk of infection.
Choice C is wrong because using hydrogen peroxide to clean the cord stump can damage the healthy tissue and delay healing.
Choice D is wrong because folding down the diaper below the cord stump can expose it to urine and feces, which can contaminate it and cause infection.
The normal range for umbilical cord separation is 5 to 15 days after birth.
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