When assessing a newborn shortly after birth, the nurse finds flat, irregular pinkish marks the forehead, the nape of the neck and the eyelids. The areas blanch when pressed with a finger. The nurse would document this finding as:
milia
telangiectatic nevi (stork bites)
nevus flammeus (port wine stain)
nevus vasculosus (strawberry mark)
The Correct Answer is B
A) Milia:
Milia are tiny white or yellowish cysts that appear on a newborn's face, particularly on the nose, chin, or forehead. They are caused by the accumulation of keratin under the skin. Milia usually disappear within a few weeks of life and are not related to the pinkish marks described in the question.
B) Telangiectatic nevi (stork bites):
This finding is consistent with telangiectatic nevi, also known as stork bites. These are flat, irregular, pinkish-red marks often found on the forehead, eyelids, and nape of the neck. They are caused by dilated capillaries in the skin and are common in newborns. The marks blanch when pressed and are usually harmless, disappearing within the first 1-2 years of life. This is the correct answer based on the description provided in the question.
C) Nevus flammeus (port wine stain):
A port wine stain is a dark red to purple, flat birthmark caused by capillary malformations. Unlike stork bites, a port wine stain does not blanch when pressed and is typically present for life. It usually appears on the face, neck, or arms, and the coloration remains the same over time.
D) Nevus vasculosus (strawberry mark):
A strawberry mark is a raised, red, and bumpy birthmark that results from proliferation of capillaries. These marks typically appear in the first few weeks of life and grow in size before eventually shrinking and disappearing by the age of 5-10 years. Strawberry marks are not flat, pinkish, or blanchable, making this option unlikely in the scenario described.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Sublimation:
Sublimation refers to a defense mechanism where a person redirects potentially negative emotions or impulses into socially acceptable behaviors or activities. While this is a psychological concept, it does not apply to the father’s behavior immediately after birth. The father's actions, such as gazing at his baby and bonding, are not a result of sublimation but rather a normal part of bonding and attachment.
B) Claiming:
Claiming refers to the process where parents identify specific traits or characteristics in their newborn that they feel emotionally connected to, such as "He has my eyes" or "She has your nose." While the father might be engaging in claiming behaviors as he bonds with his baby, this term is more focused on recognizing physical attributes, rather than the intense emotional connection and captivation that is reflected in the scenario.
C) Mutuality:
Mutuality involves the reciprocal relationship between the newborn and the parents, where both give and receive emotional responses. It develops as the baby and parent interact, such as through eye contact, touch, and vocalizations. However, mutuality is a broader, ongoing process, while the father's behavior in this instance reflects a more specific emotional attachment and admiration, which aligns more closely with engrossment.
D) Engrossment:
Engrossment refers to the intense fascination and preoccupation that a parent, especially a father, feels toward their newborn. This process is characterized by behaviors such as gazing at the baby, holding them closely, and being captivated by their every movement. The father’s behavior in this scenario—staring into his baby’s eyes and showing deep emotional engagement—fits the definition of engrossment, which is a common and normal part of the bonding process immediately after birth.
Correct Answer is A
Explanation
A) Check fetal heart rate:
The first priority when a woman's membranes spontaneously rupture is to assess fetal well-being. The nurse should immediately check the fetal heart rate (FHR) after the rupture of membranes to evaluate for any signs of fetal distress. If there are any concerns regarding the FHR, further interventions may be needed, such as adjusting the maternal position or preparing for a possible emergent delivery. Monitoring the FHR will help guide subsequent decisions regarding care.
B) Instruct her to bear down with the next contraction:
While the second stage of labor involves pushing, it is important to wait for the appropriate signs of readiness before instructing the mother to bear down. The nurse should ensure the cervix is fully dilated and that fetal descent is progressing appropriately. Rushing into pushing too early or without proper readiness can lead to maternal and fetal complications.
C) Place her legs in stirrups:
Placing the mother’s legs in stirrups is typically done once she is in the active phase of pushing (typically when the cervix is fully dilated and fetal descent is ready). It is not the first priority immediately after the membranes rupture. The nurse should first assess the fetal heart rate and ensure the woman is comfortable and ready to push before assuming the lithotomy position or placing her legs in stirrups.
D) Test a sample of the amniotic fluid for meconium:
Testing the amniotic fluid for meconium should be done if there is concern that the amniotic fluid may be stained, as meconium in the amniotic fluid can be a sign of fetal distress. However, the first action after the membranes rupture is to check the fetal heart rate. If the FHR is normal, further actions, like testing the fluid, may follow, but the priority remains assessing fetal well-being.
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