A newborn is delivered by vaginal birth at 40 weeks of gestation. Which of the following findings should the nurse report to the provider?
Acrocyanosis and caput succedaneum
Positive Babinski reflex and negative Ortolani's sign
Head circumference 40cm and chest circumference 32cm
Heart rate 160/min and respirations 40/min.
The Correct Answer is C
A. Acrocyanosis and caput succedaneum. Acrocyanosis is a normal finding in the first 24 to 48 hours as peripheral circulation adapts. Caput succedaneum represents localized edema of the scalp from pressure during labor. These findings are benign and do not require urgent provider notification.
B. Positive Babinski reflex and negative Ortolani's sign. A positive Babinski reflex is a normal neurological finding in neonates until approximately 1 year of age. A negative Ortolani's sign indicates the absence of hip click or dislocation. Both findings reflect a healthy musculoskeletal and neurological status in a newborn.
C. Head circumference 40cm and chest circumference 32cm. The head circumference typically ranges from 32 to 36 cm and should only be 2 cm larger than the chest. A 40 cm head circumference indicates macrocephaly or increased intracranial pressure. This significant discrepancy requires immediate clinical evaluation to rule out hydrocephalus.
D. Heart rate 160/min and respirations 40/min. A neonatal heart rate of 160 beats per minute falls within the normal range of 110 to 160. Respiratory rates between 30 and 60 breaths per minute are expected for a term newborn. These vital signs indicate stable cardiorespiratory transition post-delivery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Scabies causes clusters of nonpruritic blisters that crust within 7 days. Scabies lesions are characterized by intense pruritus, especially at night, rather than being nonpruritic. The rash typically involves erythematous papules and linear burrows rather than simple blistering clusters. Itching is a hypersensitivity reaction to the mite, its eggs, and its excrement.
B. Scabies eggs hatch 30 days after infection. Female mites deposit eggs into the subcutaneous burrows they create within the stratum corneum. These eggs typically hatch into larvae within 3 to 4 days, not 30 days. Rapid hatching contributes to the quick progression of the infestation and symptoms.
C. Prophylactic treatment is not recommended for household members. Scabies is highly contagious and spreads through direct, prolonged skin-to-skin contact among close contacts. All household members and sexual partners require simultaneous treatment to prevent cycles of re-infestation. Asymptomatic individuals can still harbor and transmit live mites to others nearby.
D. The infection is caused by a mite underneath the skin. The Sarcoptes scabiei mite burrows into the upper layers of the skin to live and lay eggs. This parasitic infestation triggers a delayed type 4 hypersensitivity reaction causing the symptomatic rash. Identification of these burrows is diagnostic for this specific parasitic skin condition.
Correct Answer is ["56"]
Explanation
Step 1: Find mL per hour
You have 450 mL that must infuse over 2 hours.
450÷2=225mL
Step 2: Convert mL/hr to gtt/min
gtt/min=ml/hr ×drop factor60
=225×1560
= 56.25
Step 3: Round to whole number
Correct answer: 56 gtts/min
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