A nurse is assessing a full-term newborn upon admission to the nursery. What clinical findings should the nurse report?
Rust-stained urine
Subconjunctival hemorrhage
Single palmar creases
Transient circumoral cyanosis .
The Correct Answer is C
Choice A rationale
Rust-stained urine is not a normal finding in a full-term newborn and should be reported to the provider. However, it is not typically assessed upon admission to the nursery.
Choice B rationale
Subconjunctival hemorrhage, or a small red or pink spot on the white of the eye, can occur due to the pressure changes during the birth process. It is a harmless condition that does not affect the baby’s vision and does not require treatment.
Choice C rationale
Single palmar creases, also known as “simian lines,” can be a normal variation in hand creases. However, they are also associated with certain genetic conditions, such as Down syndrome, and should be reported to the provider.
Choice D rationale
Transient circumoral cyanosis, or bluish color around the mouth, can be a normal finding in newborns when they are cold or after crying. However, if it persists, it could indicate a problem with the baby’s heart or lungs and should be reported to the provider.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice d. Assist the client to the bathroom.
Choice A rationale:
Inserting a urinary catheter is an invasive procedure and should be considered only after less invasive measures have been attempted and failed. It carries risks such as infection and trauma to the urethra.
Choice B rationale:
Pouring warm water over the client’s perineum can help stimulate urination, but it should be tried after assisting the client to the bathroom. It is a non-invasive method but not the first action to take.
Choice C rationale:
Offering a sitz bath can also help with urination by relaxing the perineal muscles, but it is not the first action to take. It is more appropriate if the client is unable to void after trying to use the bathroom.
Choice D rationale:
Assisting the client to the bathroom is the least invasive and most straightforward initial action. It allows the client to attempt to void naturally, which is preferable before trying other interventions.
Correct Answer is D
Explanation
The correct answer is choice d. The procedure is not necessary to determine the sex of the fetus.
Choice A rationale:
Chorionic villus sampling (CVS) is another prenatal test that can determine the sex of the fetus, but it is typically performed between 10-13 weeks of gestation. However, it is not the standard response to a request for amniocentesis.
Choice B rationale:
Age is not a criterion for performing an amniocentesis. This procedure can be done for various medical reasons regardless of the mother’s age.
Choice C rationale:
Scheduling an amniocentesis for the same day is not appropriate, especially since the primary purpose of amniocentesis is to diagnose genetic disorders, not to determine the sex of the fetus.
Choice D rationale:
This is the correct response because non-invasive methods like ultrasound can determine the sex of the fetus without the need for an invasive procedure like amniocentesis, which carries risks.
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