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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is B
Explanation
The correct answer is choice B. Give the vaccine intramuscularly in the anterolateral thigh.
This is because the anterolateral thigh is the recommended site for intramuscular injections in infants less than 12 months of age.
It has a large muscle mass and minimal risk of injury to nerves or blood vessels.
Choice A is wrong because informed consent is not required for routine immunizations, unless the parent or guardian requests more information or declines the vaccine.
Choice C is wrong because hepatitis B immune globulin (HBIG) is only indicated for newborns whose mothers are hepatitis B surface antigen positive (HBsAg+), as they have a high risk of acquiring the infection from their mothers.
Choice D is wrong because there is no need to delay giving the vaccine until after breastfeeding is established.
Breastfeeding does not interfere with the vaccine’s effectiveness or safety, and it does not increase the risk of adverse reactions.
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