Which physical signs could indicate a risk for hyperbilirubinemia?
Tremors
Newborn rash
Cephalohematoma
Acrocyanosis
The Correct Answer is C
Choice A reason:
Tremors are not a sign of hyperbilirubinemia, but they may indicate other problems such as hypoglycemia, hypocalcemia, or seizures. Tremors are involuntary muscle movements that can affect different parts of the body.
Choice B reason:
Newborn rash, also known as erythema toxicum, is a common and harmless skin condition that affects many newborns. It causes red spots with white or yellow centers on the face, chest, back, or limbs. It is not related to hyperbilirubinemia or liver function.
Choice C reason:
Cephalohematoma is a collection of blood under the scalp that occurs due to trauma during delivery. It can increase the risk of hyperbilirubinemia because the breakdown of red blood cells in the hematoma releases bilirubin into the bloodstream. Bilirubin is a yellow pigment that is normally processed by the liver and excreted in stool and urine. If the liver is overwhelmed by the amount of bilirubin, it can cause jaundice, which is yellowing of the skin and eyes.
Choice D reason:
Acrocyanosis is a bluish discoloration of the hands and feet that occurs in some newborns due to poor circulation. It is usually a normal and transient phenomenon that does not indicate any serious problem. It is not a sign of hyperbilirubinemia or liver dysfunction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
A soft fundus indicates uterine atony, which is a lack of muscle tone that can lead to postpartum hemorrhage. A soft fundus is an abnormal finding and should be reported to the provider. The fundus should be firm and contracted to prevent bleeding.
Choice B reason:
A fundus that is 2 fingerbreadths above the umbilicus is too high for a client who is 12 hours postpartum. The fundus should descend about 1 centimeter per hour after delivery and should be at the level of the umbilicus at 12 hours postpartum. A high fundus could indicate retained placental fragments or a full bladder, both of which can interfere with uterine contraction and cause bleeding.
Choice C reason:
A fundus that is deviated to the right of the umbilicus is also an abnormal finding for a client who is 12 hours postpartum. A deviated fundus could indicate a full bladder, which can displace the uterus and prevent it from contracting properly. The fundus should be at the midline of the abdomen.
Choice D reason:
A fundus that is firm and at the level of the umbilicus is a normal finding for a client who is 12 hours postpartum. This indicates that the uterus is involuting (returning to its pre-pregnancy size and shape) and that there is no excessive bleeding. The nurse should expect this finding and document it accordingly.
Correct Answer is ["A","B","D","E"]
Explanation
Choice A reason:
Heel to ear is a test that measures the flexibility of the newborn's hip and knee joints. The nurse should gently flex the newborn's hip and knee and bring the foot toward the ear on the same side. The closer the foot is to the ear, the higher the score. This test is part of the neuromuscular assessment for gestational age.
Choice B reason:
Popliteal angle is a test that measures the angle of flexion at the knee joint. The nurse should flex the newborn's hip and knee at 90 degrees and then extend the lower leg until resistance is felt. The smaller the angle, the higher the score. This test is also part of the neuromuscular assessment for gestational age.
Choice C reason:
Moro reflex is a test that evaluates the newborn's startle response. The nurse should hold the newborn in a semi-sitting position and then allow the head to fall back slightly. The newborn should extend and abduct the arms and legs, then flex and adduct them. This test is not part of the neuromuscular assessment for gestational age, but rather a reflex assessment for neurological function. •
Choice D reason:
Scarf sign is a test that measures the flexibility of the newborn's shoulder and elbow joints. The nurse should draw one of the newborn's arms across the chest toward the opposite shoulder. The farther the elbow can be moved across the body, the lower the score. This test is part of the neuromuscular assessment for gestational age.
Choice E reason:
Arm recoil is a test that measures the degree of flexion at the elbow joint. The nurse should extend both of the newborn's arms for 5 seconds and then release them. The arms should return to a flexed position quickly and fully. The faster and more complete the recoil, the higher the score. This test is part of the neuromuscular assessment for gestational age.
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