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 is common in newborns, especially when crying or feeding, and usually resolves on its own without intervention.
Choice B rationale
Transient strabismus, or the temporary crossing of the eyes, is normal in newborns due to underdeveloped eye muscles and usually resolves as the infant grows.
Choice C rationale
Caput succedaneum is the swelling of the scalp caused by pressure during delivery. It is usually benign and resolves within a few days without treatment.
Choice D rationale
Generalized petechiae, or small red or purple spots on the skin, can indicate a serious underlying condition such as a clotting disorder or infection and requires immediate medical evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C"]
Explanation
Choice A rationale
Delay in initiating breastfeeding can occur after a cesarean birth due to the effects of anesthesia, postoperative recovery, and the need for medical monitoring, which can delay the mother’s ability to start breastfeeding.
Choice B rationale
Routine use of intubation equipment is not standard practice during a cesarean birth. Intubation is typically reserved for patients who require general anesthesia or have complications that necessitate airway management.
Choice C rationale
The need for an indwelling urinary catheter is common during a cesarean birth. It helps to keep the bladder empty and out of the way during the procedure and is usually placed after anesthesia and removed shortly after the surgery.
Choice D rationale
Management of postpartum pain is an important topic to discuss with clients undergoing cesarean birth. Postoperative pain management may include medications and non-pharmacological methods to ensure comfort and aid in recovery.
Correct Answer is D
Explanation
Choice A rationale
Uterine contractions occur more frequently than every 15 minutes during the active phase of labor, typically every 2-3 minutes.
Choice B rationale
A fetal heart rate baseline of 166/min is considered tachycardia and may not be normal during labor.
Choice C rationale
Late decelerations are concerning and not expected as they may indicate fetal distress.
Choice D rationale
Contractions lasting about 75 seconds are expected during the active phase of labor.
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