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A nurse in the newborn unit is caring for several infants.
Which of the following situations requires the nurse's immediate attention and intervention?

A.

A newborn who is 24 hours post-delivery and has not voided

B.

A newborn who is 18 hours post-delivery and has acrocyanosis

C.

A newborn who is 12 hours post-delivery and has a temperature of 37.5°C (99.5°F)

D.

A newborn who is 24 hours post-delivery and has not passed meconium

Answer and Explanation

The Correct Answer is D

Choice A rationale
A newborn typically begins to void within 24 hours after birth, so not voiding within this time frame is not immediately concerning.
Choice B rationale
 

Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns, especially within the first few hours after birth. It is a normal finding and does not require immediate intervention.
Choice C rationale
A temperature of 37.5°C (99.5°F) is within the normal range for a newborn. Therefore, this does not require immediate attention.
Choice D rationale
Newborns typically pass meconium, the first stool, within 24 to 48 hours after birth. If a newborn has not passed meconium within 24 hours, it could indicate a problem such as meconium ileus, a complication of cystic fibrosis, or other conditions that might obstruct the bowel. This situation requires immediate attention and intervention.
 


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Related Questions

Correct Answer is ["A","C"]

Explanation

The correct answers are A. Transverse palmar creases and C. Protruding tongue.

Choice A rationale:

Transverse palmar creases, also known as a single palmar crease, are a common characteristic of Down syndrome. This feature is present in many individuals with the condition.

Choice B rationale:

Muscular hypertonicity (increased muscle tone) is not typical in Down syndrome. Instead, individuals with Down syndrome often have hypotonia (decreased muscle tone).

Choice C rationale:

A protruding tongue is a common characteristic of Down syndrome. This is due to a combination of factors, including a small oral cavity and low muscle tone.

Choice D rationale:

Large ears are not a typical feature of Down syndrome. Individuals with Down syndrome often have small or unusually shaped ears.

Choice E rationale:

Low birth weight is not specifically associated with Down syndrome. While some infants with Down syndrome may have low birth weight, it is not a defining characteristic.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"}}

Explanation

• Frequent urination: This is more likely to be associated with a UTI, as frequent urination is a common symptom of UTIs.
• Low back pain: This can be associated with both preterm labor and a UTI. Low back pain can be a sign of labor, and it can also be a symptom of a UTI.
• Temperature of 38.3°C (101°F): This is more likely to be associated with a UTI, as fever is a common symptom of infections, including UTIs.
• Strong urge to push: This is more likely to be associated with preterm labor, as an urge to push can be a sign of labor.
• Contractions every 1.5 minutes: This is more likely to be associated with preterm labor, as frequent contractions are a sign of labor.
• Pain level of 8 on a scale of 0 to 10: This can be associated with both preterm labor and a UTI. Severe pain can be a sign of labor, and it can also be a symptom of a UTI. Please note that these are potential associations and the healthcare provider should be informed immediately for further evaluation and management. It’s important to continue following the provider’s prescriptions and closely monitor the client’s condition.

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