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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["9"]
Explanation
Step 1 is: Heart rate 120 BPM = 2 points (HR > 100 BPM).
Step 2 is: Strong cry = 2 points (Strong cry/cough).
Step 3 is: Well-flexed = 2 points (Well flexed).
Step 4 is: Reflex-crying = 2 points (Cry/sneeze).
Step 5 is: Body pink; acrocyanosis present in hands and feet = 1 point (Body pink, extremities blue).
Step 6 is: Add up all the points: 2 + 2 + 2 + 2 + 1 = 9.
Answer: 9.
Correct Answer is B
Explanation
Choice A rationale
Fluid-filled vesicles on the chest are not characteristic of Koplik spots. Vesicular rashes are more commonly associated with conditions like varicella (chickenpox) or herpes zoster, where the viral replication leads to the formation of small, elevated, fluid-filled lesions on the skin surface.
Choice B rationale
Koplik spots are pathognomonic for measles, appearing as small, irregular, bright red spots with bluish-white centers on the buccal mucosa, typically opposite the molars. They represent necrotic epithelial cells in the buccal mucosa and are an early diagnostic sign, often appearing 2-3 days before the generalized rash.
Choice C rationale
Enlarged parotid glands are characteristic of mumps, a viral infection affecting the salivary glands, particularly the parotid glands. This condition leads to swelling and tenderness in the areas anterior to the ears and below the jawline, distinct from the oral lesions seen in measles.
Choice D rationale
A gray pseudomembrane covering the pharynx is a hallmark sign of diphtheria, a bacterial infection caused by *Corynebacterium diphtheriae*. This pseudomembrane is a tough, adherent lesion composed of fibrin, bacteria, and necrotic cells that can obstruct the airway, unrelated to measles.
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