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 D
Explanation
A. "Apply cold compresses when your child expresses pain." Cold can cause vasoconstriction, which may precipitate a sickle cell crisis by reducing blood flow to the extremities, thus increasing the risk of sickling of red blood cells. Warm compresses are recommended to help alleviate pain by promoting blood flow.
B. "Restrict outdoor play activity to 1 hour per day." While it's important to monitor physical activity to avoid overexertion, restricting outdoor play to a specific time frame without considering other factors like hydration and rest isn't the right approach. Physical activity is important but should be balanced with adequate hydration and rest.
C. "Monitor your child's temperature daily." While monitoring temperature is important, it isn't specifically critical on a daily basis unless there is a suspicion of infection. The primary focus should be on hydration and recognizing signs of infection.
D. "Offer fluids to your child multiple times every day." Hydration is crucial for children with sickle cell anemia as it helps to prevent sickling of cells by maintaining good blood flow and preventing dehydration, which can trigger a crisis.
Correct Answer is B
Explanation
A. The baseline FHR can be obtained via ultrasound or auscultation: True. The baseline fetal heart rate can be assessed using ultrasound or auscultation, which are standard methods.
B. The baseline FHR can be obtained during contractions: False. The baseline fetal heart rate should be obtained in the absence of uterine contractions because contractions can temporarily alter the heart rate, making it difficult to determine the true baseline.
C. The baseline FHR is normal between 110-160 bpm: True. This is the accepted normal range for baseline fetal heart rates.
D. The baseline FHR is assessed over a 10-minute period: True. The baseline is typically assessed over a 10-minute window to account for variability and provide an accurate average.
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