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 A

Explanation

A. Auscultating the client's left arm for a bruit helps assess the patency and function of the arteriovenous fistula. A bruit indicates normal blood flow through the fistula.

B. Comparing blood pressure in both arms every 2 hours is not specifically related to monitoring the arteriovenous fistula. Blood pressure comparison may be done periodically but is not as directly relevant to postoperative care of the fistula.

C. Instructing the client to keep the left arm in a dependent position may help with venous return but is not the primary action for monitoring the arteriovenous fistula's patency and function.

D. Encouraging the client to restrict movement of the left arm is not necessary unless there are specific instructions from the surgeon. Encouraging gentle movement and range of motion exercises may actually be beneficial for preventing stiffness and promoting healing.

A. Dependent edema B. Pericardial friction rub C. Paradoxical pulse D. Substernal chest pain

Correct Answer is D

Explanation

A. Dependent edema may be present in pericarditis but is not typically the priority finding unless it indicates worsening heart failure.

B. Pericardial friction rub is a classic finding in pericarditis but is not the priority unless it indicates cardiac tamponade, which is a medical emergency.

C. Paradoxical pulse may occur in pericarditis but is not necessarily the priority finding unless it is severe and indicative of cardiac tamponade.

D. Substernal chest pain is the priority finding in pericarditis as it indicates inflammation of the pericardium, which can lead to complications such as myocardial infarction or cardiac

tamponade. Prompt intervention is necessary to alleviate pain and prevent complications.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is postoperative following creation of an arteriovenous fistula in the left arm. Which of the following actions should the nurse include in the plan?

Correct Answer is A

Explanation

A nurse is assessing a client who has pericarditis. Which of the following findings is the priority?

Correct Answer is D

Explanation

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