A nurse is assessing a 1-hour-old newborn.
Which of the following findings should the nurse report to the provider?
Transient circumoral cyanosis.
Transient strabismus.
Caput succedaneum.
Generalized petechiae.
The Correct Answer is D
Choice A rationale
Transient circumoral cyanosis, a bluish discoloration around the mouth, can be a normal finding in the immediate newborn period, especially during periods of crying or temperature instability. It is often related to immature peripheral circulation and typically resolves as the newborn's circulatory system adapts to extrauterine life, without requiring intervention.
Choice B rationale
Transient strabismus, or crossed eyes, is a common and normal finding in newborns due to immature neuromuscular control of eye movements. The newborn's eye muscles are still developing coordination, and occasional misalignment is expected. This usually resolves spontaneously by 3 to 4 months of age as vision matures.
Choice C rationale
Caput succedaneum, a localized soft tissue edema of the scalp, is a common finding in newborns after vaginal birth. It results from pressure on the presenting part of the head during labor. It crosses suture lines and typically resolves within a few days, representing a benign finding that does not require medical intervention.
Choice D rationale
Generalized petechiae, which are small, pinpoint hemorrhages, are an abnormal finding in a 1-hour-old newborn and warrant immediate reporting to the provider. While scattered petechiae over the presenting part may occur with a difficult delivery, generalized petechiae can indicate a coagulation disorder, infection, or other serious underlying pathological condition requiring prompt evaluation and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"B"}}
Explanation
Placement of an internal fetal spiral electrode is contraindicated because it requires ruptured membranes and no active vaginal bleeding. In cases of antepartum bleeding, especially without rupture of membranes, it increases infection risk and fetal injury.
Laboratory testing (CBC, blood type, Rh factor, coagulation studies) is anticipated to evaluate maternal blood loss, anemia, blood type compatibility, and coagulation status. These are essential for managing bleeding risk and potential transfusions.
IV fluids are anticipated to maintain maternal hemodynamic stability and manage possible blood loss, preventing hypovolemia and hypotension.
Abdominal ultrasound is anticipated for placental localization, fetal wellbeing assessment, and to differentiate causes of bleeding (placenta previa vs. abruption).
Betamethasone administration is anticipated at 30 weeks to accelerate fetal lung maturity in case of preterm delivery.
Continuous fetal heart rate (FHR) monitoring is essential to assess fetal status and detect hypoxia or distress promptly.
Digital cervical exam is contraindicated due to risk of exacerbating bleeding and infection in the presence of unknown placental position or bleeding source.
Correct Answer is B
Explanation
Choice A rationale
Group B Streptococcus (GBS) colonization in a pregnant client does not typically necessitate a cesarean birth. The primary concern with GBS is the risk of vertical transmission to the neonate during vaginal birth, which can lead to severe neonatal infections like sepsis, meningitis, or pneumonia. Cesarean section is generally reserved for obstetric indications and does not eliminate the risk of GBS transmission if membranes rupture.
Choice B rationale
Intravenous antibiotic prophylaxis is the cornerstone of preventing neonatal GBS disease in colonized mothers. The recommended antibiotics, typically penicillin or ampicillin, are administered during labor once ruptured membranes or active labor commence. This intrapartum treatment significantly reduces bacterial colonization in the birth canal, thereby minimizing the neonate's exposure to the bacteria during passage.
Choice C rationale
A vaginal culture for GBS is typically performed between 36 and 37 weeks of gestation as part of routine prenatal screening. If the client has already been screened and identified as GBS positive at 36 weeks, repeating the culture during active labor is not indicated as the colonization status is already known, and the focus shifts to prophylaxis.
Choice D rationale
Metronidazole is an antibiotic primarily effective against anaerobic bacteria and certain parasites. It is not the drug of choice for Group B Streptococcus prophylaxis. Penicillin or ampicillin are the preferred antibiotics for GBS intrapartum prophylaxis due to their effectiveness against GBS and their favorable safety profile for both the mother and the fetus.
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