Which newborn assessment finding would require the nurse to report to the health care provider?
The newborn who has cyanotic hands and feet.
The newborns whose head turns toward the cheek being stroked
The newborn whose toes curl when the lateral heel is stroked
The newborn who extends the arms when hearing a loud noise
The Correct Answer is A
A. The newborn who has cyanotic hands and feetCyanosis, a bluish or purplish discoloration of the skin, in the hands and feet of a newborn can indicate a breathing problem or poor circulation. This requires prompt evaluation by a healthcare provider.
B. The newborn whose head turns toward the cheek being stroked. This describes the rooting reflex, which is normal.
C. The newborn whose toes curl when the lateral heel is stroked. This describes the Babinski reflex, which is also normal for infants.
D. The newborn who extends the arms when hearing a loud noise. This describes the Moro reflex, which is normal and should not require reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Complication: Otitis Media
Anatomical Changes:
- Small external ear structure: Infants born with a cleft palate often have smaller external ear structures, which can affect the drainage of fluids and increase the risk of infections.
- Horizontal eustachian tubes: Eustachian tubes in individuals with cleft palate are typically more horizontal than normal, impairing the drainage of fluid from the middle ear.
- Large tongue: A large tongue may obstruct the upper airway and interfere with normal swallowing and speaking functions.
Complication: Otitis Media
- Due to the anatomical changes associated with cleft palate, such as horizontal eustachian tubes and impaired drainage, individuals are prone to recurrent middle ear infections (otitis media). These infections can lead to fluid accumulation behind the eardrum, which can further impair hearing and potentially lead to more serious complications if untreated.
Priority Interventions:
- Ear drops (for otitis media): Ear drops containing antibiotics may be prescribed to treat bacterial infections in the middle ear, which are common in individuals with cleft palate.
- Rationale: Ear drops help to directly treat the infection in the ear canal and middle ear, reducing inflammation and preventing complications such as hearing loss or spread of infection.
- Corticosteroids (for inflammation): Corticosteroids may be used to reduce inflammation in the ear canal and middle ear, particularly in cases of severe otitis media.
- Rationale: Corticosteroids help to decrease swelling and inflammation, which can improve symptoms and aid in the healing process of the ear.
Correct Answer is A
Explanation
A. Have you passed any clots? This is important to assess for potential postpartum hemorrhage, which can be indicated by passage of large clots.
B. Do you have to go to the bathroom? This does not directly address the issue of excessive bleeding.
C. When was the last time you changed your pad? This provides information about the amount of bleeding but does not address clotting.
D. Are you having any cramping? Cramping is common postpartum but does not directly assess for hemorrhage.
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