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 A
Explanation
A. slight yellow vaginal discharge: Gonorrhea often presents with a purulent or yellowish vaginal discharge in females. It is one of the common symptoms along with pelvic pain and dysuria.
B. Decrease in urinary frequency: Gonorrhea can actually increase urinary frequency or cause dysuria. A decrease in frequency is not typical for gonorrhea.
C. frothy, white vaginal discharge: This is more characteristic of Trichomoniasis, not gonorrhea. Gonorrhea usually presents with a thicker, more purulent discharge.
D. low grade fever for three (3) days: While fever can be associated with many infections, it is not a common primary symptom of gonorrhea in the absence of more specific symptoms like discharge or pelvic pain.
Correct Answer is ["B","C","E"]
Explanation
A. Stand directly in front of the client when talking: Standing directly in front of an agitated client can be seen as confrontational and might escalate the situation. It is better to stand at an angle and maintain a non-threatening posture.
B. Avoid wearing necklaces during client care: Wearing necklaces or other loose accessories can pose a safety risk if a client becomes aggressive and tries to grab or pull them, potentially causing injury.
C. Provide immediate verbal feedback for escalating behavior: Immediate feedback can help de-escalate potentially aggressive behavior by addressing issues before they become more serious. It also reinforces appropriate behavior and sets clear boundaries.
D. Bring security with you for all client interactions: Bringing security for all interactions is impractical and can create an atmosphere of distrust. Security should be involved only when there is a credible risk of violence.
E. Review the layout of the facility: Understanding the layout of the facility, including exits and potential hazards, helps in planning for safe interactions and knowing escape routes if a situation escalates.
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