A nurse in a newborn nursery is performing assessments on four neonates that are all less than 24 hours old. The nurse should plan to notify the provider of which of the following findings?

Head circumference 1 cm greater than chest

Positive Babinski reflex on bilateral feet

Passage of meconium stool

Pinna below the outer canthus of the eye

Answer and Explanation

The Correct Answer is D

A. A head circumference 1 cm greater than the chest is within normal variations and does not typically require immediate notification.

B. A positive Babinski reflex is a normal finding in newborns and does not warrant immediate notification.

C. Passage of meconium stool within the first 24 hours of life is considered normal and does not require notification.

D. The pinna (ear) below the outer canthus of the eye can indicate a condition called low-set ears, which may be associated with genetic syndromes or other abnormalities. This finding warrants notification to the provider for further evaluation.

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Correct Answer is D

Explanation

A. Taking the client to the bathroom after administering a preoperative sedative increases the risk of falls.
B. Surgical site verification should be completed before administering the preoperative medication.
C. Teaching should be done before giving the medication, as the sedative may impair learning and recall.
D. Raising the side rails helps ensure client safety by preventing falls after the medication has been administered.

A. Set up the sterile field 7.6 cm (3 in) below waist level. B. Hold the bottle of sterile solution with the palm over the label while pouring. C. Place the sterile items within 1 cm (0.4 in) of the edge of the sterile border. D. Place the lid of a bottle of sterile solution within the sterile field.

Correct Answer is C

Explanation

A. Set up the sterile field 7.6 cm (3 in) below waist level - While it's important to maintain a sterile field, the specific height mentioned is not a standard requirement.

B. Hold the bottle of sterile solution with the palm over the label while pouring - This is

incorrect because it increases the risk of contaminating the solution by touching the label.

C. Place the sterile items within 1 cm (0.4 in) of the edge of the sterile border - This is the correct action as it ensures that sterile items are easily accessible without reaching over the sterile field, minimizing the risk of contamination.

D. Place the lid of a bottle of sterile solution within the sterile field - Placing the lid inside the sterile field increases the risk of contamination, as the lid is not considered sterile.

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A nurse in a newborn nursery is performing assessments on four neonates that are all less than 24 hours old. The nurse should plan to notify the provider of which of the following findings?

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