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16. A nurse is caring for a newborn who is 4 hr old.
Nurses' Notes
Large ecchymotic caput succedaneum noted on occiput with molding of the skull. Anterior fontanel level and soft.
Newborn's respirations are shallow and irregular.
Newborn's skin color is consistent with their genetic background. Acrocyanosis noted. The newborn is active and moves all extremities except for left arm. Left arm remains at side during Moro reflex. Bilateral gluteal folds equal. Base of spine closed.
Breastfed vigorously for 30 min.
Drag 1 condition and 1 client finding to fill in each blank in the following sentence.
The newborn most likely has as evidenced by Condition a clavicle fracture neonatal abstinence syndrome (NAS) developmental dysplasia of the hip (DDH) a subgaleal hemorrhage a congenital cardiac defect
16. A nurse is caring for a newborn who is 4 hr old.
Nurses' Notes
Large ecchymotic caput succedaneum noted on occiput with molding of the skull. Anterior fontanel level and soft.
Newborn's respirations are shallow and irregular.
Newborn's skin color is consistent with their genetic background. Acrocyanosis noted. The newborn is active and moves all extremities except for left arm. Left arm remains at side during Moro reflex. Bilateral gluteal folds equal. Base of spine closed.
Breastfed vigorously for 30 min.
Drag 1 condition and 1 client finding to fill in each blank in the following sentence.
The newborn most likely has as evidenced by Condition a clavicle fracture neonatal abstinence syndrome (NAS) developmental dysplasia of the hip (DDH) a subgaleal hemorrhage a congenital cardiac defect
The Correct Answer is ["Moro reflex color of extremities head assessment maternal urine toxicology screen gluteal folds"]
Subgaleal hemorrhage is a rare but potentially serious condition in newborns characterized by bleeding beneath the scalp's galea aponeurotica, a fibrous tissue layer between the scalp and the skull.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A Covering the umbilical cord stump with the diaper can create a moist environment, which may increase the risk of bacterial growth and infection.
B. Washing the cord stump with soap and water may disrupt the natural drying process and increase the risk of infection
C. Applying petroleum jelly or any other substance to the umbilical cord stump is not necessary and may increase the risk of infection.
Correct Answer is B
Explanation
53. A nurse is caring for a client who has a suspected ectopic pregnancy at 8 weeks of gestation. An ectopic pregnancy occurs when the fertilized egg implants outside the uterus, most commonly in the fallopian tube. One of the hallmark symptoms of an ectopic pregnancy is unilateral, cramp-like abdominal pain depending on the location of the pregnancy.
A. Uterine enlargement greater than expected for gestational age is not expected in an ectopic pregnancy because the fertilized egg implants outside the uterus, so there is no uterine enlargement.
C. Severe nausea and vomiting are more commonly associated with conditions such as hyperemesis gravidarum or early pregnancy symptoms but are not specific to ectopic pregnancy.
D. A large amount of vaginal bleeding may occur in some cases of ectopic pregnancy, but it is not a consistent or defining characteristic.
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