During a physical assessment of a newborn, the nurse observes bluish markings across the newborn's lower back. The nurse interprets this finding as:
Select one:

Milia.

Dermal melanosis.

Stork bites.

Birth trauma.

Answer and Explanation

The Correct Answer is B

Choice A Reason: Milia. This is an incorrect answer that describes a diﬀerent skin condition. Milia are tiny white or yellow cysts that appear on the nose, chin, or cheeks of newborns. They are caused by the retention of keratin in the sebaceous glands or hair follicles. They usually disappear within a few weeks without treatment.

Choice B Reason: Dermal melanosis. This is a correct answer that explains the finding of bluish markings across the newborn's lower back. Dermal melanosis. This is because dermal melanosis, also known as Mongolian spots, is a common benign skin condition that aﬀects newborns of Asian, African, or Hispanic descent. It is characterized by bluish-gray or brown patches of pigmentation on the lower back, butocks, or extremities. It is caused by the migration of melanocytes from the neural crest to the dermis during embryonic development. It usually fades by 2 to 4 years of age.

Choice C Reason: Stork bites. This is an incorrect answer that refers to another skin condition. Stork bites, also known as salmon patches or nevus simplex, are ﬂat pink or red marks that appear on the forehead, eyelids, nose, upper lip, or nape of the neck of newborns. They are caused by dilated capillaries in the superficial dermis. They usually fade by 18 months of age.

Choice D Reason: Birth trauma. This is an incorrect answer that implies an injury or damage to the newborn's skin or tissues during labor and delivery. Birth trauma can cause bruises, abrasions, lacerations, fractures, or nerve injuries. It is not related to bluish markings on the lower back.

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Correct Answer is D

Explanation

Choice A Reason: "Your body is responding to the events of labor, just like after a tough workout." This is an inaccurate statement that does not explain the cause of the contractions or reassure the client.

Choice B Reason: "This could be a sign that your body is trying to get rid of retained placental fragments." This is an alarming statement that may scare the client and imply that something is wrong. Retained placental fragments are rare and usually cause heavy bleeding, fever, and infection.

Choice C Reason: "Let me check your vaginal discharge just to make sure everything is fine." This is an unnecessary statement that does not answer the client's question or provide any information.

Choice D Reason:"The baby's sucking releases oxytocin which causes your uterus to contract." This is a correct statement that explains the physiological mechanism of the contractions and reassures the client that they are normal and beneficial.

A. Assisting with the delivery of the placenta and ensuring that the fundus is contracted afterward. B. Palpating the woman's fundus for position and firmness. C. Encouraging the woman to push with her contractions. D. Alleviating perineal discomfort with the application of ice packs.

Correct Answer is A

Explanation

Choice A Reason: Assisting with the delivery of the placenta and ensuring that the fundus is contracted afterward. This is an appropriate action for the nurse to perform during the third stage of labor, as it helps complete the process of labor and prevent complications.

Choice B Reason: Palpating the woman's fundus for position and firmness. This is an action that is done after the delivery of the placenta, not during. It is important to monitor the fundal height, location, and consistency to assess uterine involution and bleeding.

Choice C Reason: Encouraging the woman to push with her contractions. This is an action that is done during the second stage of labor, not the third. The second stage of labor is the period from full cervical dilation to the birth of the baby. The nurse's role is to support and coach the woman to push eﬀectively with her contractions.

Choice D Reason: Alleviating perineal discomfort with the application of ice packs. This is an action that is done after the delivery of the placenta, not during. It is a comfort measure that can reduce swelling, pain, and inﬂammation in the perineal area.

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During a physical assessment of a newborn, the nurse observes bluish markings across the newborn's lower back. The nurse interprets this finding as: Select one:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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During a physical assessment of a newborn, the nurse observes bluish markings across the newborn's lower back. The nurse interprets this finding as:
Select one: