A nurse in the newborn nursery is receiving a report on four newborns. Which of the following newborns should the nurse see first?
A newborn who is 8 hr old and has acrocyanosis.
A newborn who is 18 hr old and has not voided.
A newborn who is 24 hr old and has not passed meconium.
A newborn who is 12 hr old and has an axillary temperature of 37.8°C (100° F).
The Correct Answer is D
Choice A rationale:
Acrocyanosis, or bluish discoloration of the hands and feet, is common in the first 24 hours after birth and is typically not a cause for concern.
Choice B rationale:
A newborn not voiding within 18 hours may need evaluation, but it is not as urgent as a potential infection.
Choice C rationale:
A newborn who is 24 hours old and has not passed meconium is not the most critical concern among the options provided. While meconium (the baby's first stool) should be passed within the first 24-48 hours, a slight delay may not be an immediate cause for concern.
Choice D rationale:
The nurse should prioritize seeing the newborn with an axillary temperature of 37.8°C (100° F), as this could indicate an infection or other serious condition requiring immediate attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Iron is crucial for the development of hemoglobin, which carries oxygen to all parts of the body, including the bones, but it does not directly facilitate bone growth.
Choice B rationale:
While newborns do metabolize iron, their iron stores are limited, and breast milk alone may not meet their iron needs.
Choice C rationale:
When educating a parent about the use of iron-fortified formula for their newborn, it is essential to convey that newborns have a limited store of iron, which begins to deplete around the age of 6 months.
Choice D rationale:
Iron facilitating eyesight development is not a relevant aspect to consider when discussing the use of iron-fortified formula for a newborn. While iron is essential for various physiological functions, it is not specifically linked to eyesight development.
Correct Answer is A
Explanation
Choice A rationale:
Cephalhematoma is the correct answer because it presents as a swelling on the newborn's head confined to one cranial bone and does not cross suture lines. It usually resolves on its own within a few weeks to months but can increase the risk of jaundice due to the breakdown of red blood cells in the hematoma.
Choice B rationale:
Nevus flammeus, also known as a port-wine stain, is a type of vascular birthmark. It presents as a flat, pink, or red mark on the skin and does not involve swelling of the head. This choice is unrelated to the findings described in the question and is therefore incorrect.
Choice C rationale:
Caput succedaneum refers to a diffuse, soft tissue swelling of the scalp that does cross suture lines. It is caused by pressure on the head during delivery, leading to edema and bruising. It typically resolves within a few days after birth.
Choice D rationale:
Molding refers to the shaping of the fetal head during childbirth as it passes through the birth canal. It may cause temporary elongation or molding of the head, but it does not present as a localized swollen area. This choice is not applicable to the findings mentioned in the question and is thus incorrect.
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