The practical nurse (PN) receives shift reports for four newborns in the full-term newborn nursery. Which infant should the PN assess first?
The six-hour-old with a large sacral "stork bite".
The two-day-old with negative Ortolani's sign.
The ten-hour-old with circumoral cyanosis.
The one-day-old with a positive Babinski's reflex.
The Correct Answer is C
Circumoral cyanosis, which is bluish discoloration around the mouth, can be a sign of inadequate oxygenation. It suggests that there may be an issue with the infant's respiratory or cardiovascular system, potentially indicating respiratory distress or a cardiac problem. Prompt assessment and intervention are necessary to determine the cause of the cyanosis and ensure the infant's well-being.
A. The six-hour-old infant with a large sacral "stork bite" refers to a common birthmark caused by dilated blood vessels. While it may be important to assess the birthmark and document its presence, it is not an urgent concern requiring immediate attention.
B. The two-day-old infant with a negative Ortolani's sign refers to a specific maneuver used to assess for developmental hip dysplasia or dislocation. A negative Ortolani sign indicates that there is no evidence of hip dislocation. While it is important to assess the infant's hips and document the findings, it does not require immediate attention.
D. The one-day-old infant with a positive Babinski's reflex refers to an abnormal response in which the infant's toes fan out and the big toe dorsiflexes when the sole of the foot is stimulated. While a positive Babinski's reflex can be a normal finding in infants under a certain age, it is important to assess the infant's neurological status. However, it does not require immediate attention compared to the infant with circumoral cyanosis, which indicates potential respiratory or cardiovascular distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Knowing the type of uterine incision from the previous cesarean section is crucial when considering the option of vaginal birth after cesarean (VBAC). The type of incision can provide important insights into the potential risks and complications associated with a trial of labor.
Specifically, a low transverse uterine incision is considered the most favorable for VBAC, as it has a lower risk of uterine rupture compared to other types of incisions, such as a classical or vertical incision.
A. While information about the client's intent regarding breastfeeding of the newborn is important for providing appropriate support and education, it does not have a direct impact on the decision-making process for VBAC.
C. A history of contracting Herpes simplex virus is relevant to the client's overall health and may have implications for the management of the pregnancy, but it is not directly related to the decision regarding VBAC.
D. The religious preference of the client's family, while important for respecting cultural and spiritual beliefs, does not have a direct impact on the decision-making process for VBAC.
Correct Answer is ["B","E"]
Explanation
Correct:
B- Making these changes will also help me avoid other chronic health conditions. This statement indicates an understanding because the client recognizes that the lifestyle changes discussed will not only help prevent or manage diabetes but also have a positive impact on other chronic health conditions such as cardiovascular disease and obesity.
E- If I have symptoms like increased thirst and urination, I should come in and get my blood sugar checked. This statement indicates an understanding because the client acknowledges the importance of monitoring their blood sugar levels if they experience symptoms commonly associated with diabetes, such as increased thirst and urination.
Incorrect choices:
A- If my fasting blood sugar is less than 100 next time, I can go back to my usual eating habits. This statement indicates a misunderstanding. It suggests that as long as the client's fasting blood sugar is below 100, they can resume their previous eating habits, which is not accurate. It's important to emphasize that long-term lifestyle changes are necessary, regardless of individual blood sugar readings.
C- I can never eat sugar again. This statement indicates a misunderstanding. While it's important to minimize the consumption of sugary foods and beverages, it's not necessary to completely eliminate all sugar from the diet. Moderation and mindful consumption are key.
D- If I make the changes we talked about, I will not get type 2 diabetes. This statement indicates a misunderstanding. While making positive lifestyle changes can significantly reduce the risk of developing type 2 diabetes, it does not guarantee complete prevention. Genetic and other factors can still influence an individual's susceptibility to the condition.
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