A newborn is delivered by vaginal birth at 40 weeks of gestation.
Which of the following findings should the nurse report to the provider?
Heart rate 160/min and respirations 40/min.
Head circumference 40cm and chest circumference 32cm.
Positive Babinski reflex and negative Ortolani's sign.
Acrocyanosis and caput succedaneum.
The Correct Answer is B
Choice A rationale
A newborn's heart rate typically ranges from 120 to 160 beats per minute, and respirations are normally between 30 and 60 breaths per minute. A heart rate of 160/min and respirations of 40/min fall within these normal physiological ranges for a newborn, indicating adequate cardiovascular and respiratory adaptation to extrauterine life.
Choice B rationale
The average head circumference for a full-term newborn ranges from 33 to 35 cm, and the chest circumference is typically 2 to 3 cm less than the head circumference. A head circumference of 40 cm is significantly larger than the normal range, and a chest circumference of 32 cm suggests an abnormal head-to-chest ratio. These measurements could indicate hydrocephalus or other developmental anomalies and warrant immediate reporting to the provider for further assessment.
Choice C rationale
A positive Babinski reflex, characterized by dorsiflexion of the big toe and fanning of the other toes, is a normal neurological finding in newborns and infants up to 12-24 months of age, indicating an immature corticospinal tract. A negative Ortolani's sign indicates the absence of hip dislocation or dysplasia, which is a normal and desired finding, reflecting stable hip joints.
Choice D rationale
Acrocyanosis, which is the bluish discoloration of the hands and feet, is a common and normal finding in newborns during the first 24 to 48 hours after birth due to immature peripheral circulation. Caput succedaneum, a localized swelling of the scalp that crosses suture lines, is also a common and benign finding resulting from pressure during vaginal birth, typically resolving spontaneously within a few days.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Routinely administering Rho(D) immune globulin at 28 weeks of gestation is a standard prophylactic measure for Rh-negative pregnant clients. This timing provides protection against potential sensitization from fetal red blood cells that may cross the placenta during the third trimester, minimizing the risk of alloimmunization and hemolytic disease of the newborn.
Choice B rationale
A spontaneous abortion, regardless of gestational age, involves a potential mixing of maternal and fetal blood, especially if the fetus is Rh-positive. Administering Rho(D) immune globulin prevents the Rh-negative mother from developing antibodies to the Rh factor, thereby protecting future Rh-positive pregnancies from hemolytic disease.
Choice C rationale
Administering Rho(D) immune globulin within 72 hours following delivery of an Rh-positive infant is crucial for Rh-negative mothers. This prevents the mother from becoming sensitized to the Rh antigen after exposure to fetal red blood cells during birth. If sensitization occurs, subsequent Rh-positive pregnancies could be affected by hemolytic disease.
Choice D rationale
Amniocentesis, a procedure involving needle insertion into the uterus, carries a risk of fetomaternal hemorrhage and potential exposure of an Rh-negative mother to Rh-positive fetal blood. Administering Rho(D) immune globulin following this procedure is a prophylactic measure to prevent maternal sensitization and protect future Rh-positive pregnancies. .
Correct Answer is B
Explanation
Choice A rationale
Allowing a child with hemophilia to participate in any sport without restriction significantly increases the risk of severe bleeding episodes, especially in contact sports. Hemophilia involves a deficiency in clotting factors, making even minor trauma potentially life-threatening due to uncontrolled hemorrhage, which can lead to joint damage, organ damage, or intracranial bleeding, severely impacting their long-term health and mobility.
Choice B rationale
Encouraging participation in age-appropriate, low-impact activities like cycling with proper protective gear promotes physical activity and psychosocial development. This approach minimizes the risk of traumatic injuries that could trigger bleeding while still fostering a sense of normalcy and social integration. Regular physical activity also helps maintain muscle strength and joint integrity, which can be beneficial in managing hemophilia.
Choice C rationale
Completely restricting a child with hemophilia from all sports or physical activity can negatively impact their physical and psychological well-being. While safety is paramount, total avoidance can lead to muscle atrophy, obesity, and social isolation. A balanced approach that allows for modified, safe activities is crucial for holistic development, promoting self-esteem and peer interaction.
Choice D rationale
Discouraging activities like bike riding or skateboarding even with classmates, implies excessive restriction. While high-risk activities should be avoided, moderate-risk activities can be managed with appropriate precautions, such as helmets and padding. This extreme limitation can hinder the child's physical development, social integration, and mental health, leading to feelings of difference and isolation from peers.
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