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

Answer and Explanation

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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Correct Answer is A

Explanation

The correct answer is choice A.Factor II, also known as prothrombin, is one of the coagulation factors that are activated by vitamin K.Vitamin K is a cofactor for the carboxylation of specific glutamic acid groups in coagulation factors II, VII, IX, and X.

This process is essential for the activation of these factors in the coagulation cascade.

Choice B is wrong because factor V is not a vitamin K-dependent coagulation factor.

Factor V is activated by thrombin and acts as a cofactor for factor Xa in the conversion of prothrombin to thrombin.

Choice C is wrong because factor VIII is not a vitamin K-dependent coagulation factor.

Factor VIII is activated by thrombin and acts as a cofactor for factor IXa in the activation of factor X.

Choice D is wrong because factor XI is not a vitamin K-dependent coagulation factor.

Factor XI is activated by factor XIIa and activates factor IX in the intrinsic pathway of coagulation.

Normal ranges for coagulation factors are:

• Factor II: 70-120% of normal activity

• Factor V: 50-150% of normal activity

• Factor VIII: 50-150% of normal activity

• Factor IX: 50-150% of normal activity

• Factor X: 70-140% of normal activity

• Factor XI: 70-150% of normal activity

A. Hypersensitivity B. Glaucoma C. Cataracts D. Strabismus

Correct Answer is A

Explanation

The correct answer is choice A. Hypersensitivity.Erythromycin eye ointment is an antibiotic that can cause allergic reactions in some newborns, such as irritation, redness, swelling, or cloudy eyes.

This is a potential adverse reaction to this medication that the nurse should monitor for.

Choice B. Glaucoma is wrong because glaucoma is a condition that causes increased pressure in the eye and can damage the optic nerve.

It is not caused by erythromycin eye ointment.

Choice C. Cataracts is wrong because cataracts are a condition that causes clouding of the lens of the eye and can impair vision.

It is not caused by erythromycin eye ointment.

Choice D. Strabismus is wrong because strabismus is a condition that causes misalignment of the eyes and can affect depth perception.

It is not caused by erythromycin eye ointment.

Erythromycin eye ointment is used to prevent ophthalmia neonatorum, which is an infection of the eye surface that affects newborns within the first month of life.It can be caused by bacteria such as chlamydia or gonorrhea that can enter the baby’s eyes during childbirth and cause permanent damage to the corneas.Erythromycin eye ointment can help prevent vision loss caused by these bacteria.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is reviewing laboratory results for a newborn who received vitamin K injection at birth. Which of the following coagulation factors should be activated by vitamin K?

Correct Answer is A

Explanation

A nurse is caring for a newborn who has received erythromycin eye ointment as prophylaxis for ophthalmia neonatorum. What should the nurse monitor for as a potential adverse reaction to this medication?

Correct Answer is A

Explanation

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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?