The practical nurse (PN) receives shift report for four newborns in the full-term newborn nursery.
Which infant should the PN assess first?
The ten-hour-old with circumoral cyanosis.
The one-day-old with a positive Babinski's reflex
The two-day old with negative Ortolani's sign
The six-hour-old with a large sacral "stork bite"
The Correct Answer is A
Circumoral cyanosis is a bluish discoloration around the mouth that indicates inadequate oxygenation. It is an abnormal finding in a full-term newborn and requires immediate assessment and intervention by the PN.
The other options are not correct because:
- A positive Babinski's reflex is a normal finding in newborns that indicates intact neurological function. It is elicited by stroking the sole of the foot and observing the fanning of the toes.
- A negative Ortolani's sign is a normal finding in newborns that indicates no hip dislocation or dysplasia. It is elicited by abducting the hips and feeling for any clicking or clunking sensation.
- A large sacral "stork bite" is a common benign birthmark that appears as a reddish patch on the lower back or nape of the neck. It usually fades within the first year of life and does not require any treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. Notify the charge nurse of the client's concerns about surgery. Choice A rationale:
Reminding the client that the consent has already been obtained does not address the client's current fears and uncertainty about undergoing the surgery. It may come across as dismissive and unsupportive of the client's emotional needs.
Choice B rationale:
This is the correct answer because notifying the charge nurse of the client's concerns about surgery allows the nursing team to provide the necessary support and address the client's emotional needs appropriately. The charge nurse can assess the client's anxiety level, discuss the procedure, and involve the healthcare provider if needed to ensure the client is well-
informed and comfortable with their decision. Choice C rationale:
Documenting the client's expressed concerns about the surgery is essential for accurate documentation but does not provide the immediate support and intervention the client may require.
Choice D rationale:
Encouraging the client to continue with the scheduled surgery without addressing their fears and uncertainty may not be appropriate. The client's emotional well-being should be a priority, and they should feel supported in their decision-making process.
Correct Answer is B
Explanation
The correct answer is choice B: Children need time to actively explore their environment. Choice A rationale:
Playpens do provide a sense of security for the child, but confining the child solely to the playpen might hinder their developmental needs. While it is essential to have a safe space for a toddler, children also require opportunities to explore and engage with their environment actively.
Choice B rationale:
The practical nurse (PN) should use this rationale when responding to the parent. Children, especially toddlers, learn and develop crucial skills through active exploration of their environment. Being confined to a playpen for extended periods may limit their opportunities for learning, hinder their physical development, and restrict social interaction, which are essential aspects of their growth.
Choice C rationale:
While playpens can provide a safe environment for a toddler when used appropriately and under supervision, keeping the child confined for the sole purpose of preventing dirtiness is not recommended. Overusing playpens can hinder a child's natural curiosity and desire to explore, potentially affecting their overall development.
Choice D rationale:
While over-concern about appearance can be harmful in some contexts, it is not directly related to the child being kept in a playpen to avoid getting dirty. The primary concern here is about providing the child with adequate opportunities for exploration, growth, and development, rather than focusing solely on appearance.
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