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 .

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A rationale
Ensuring the newborn’s diaper is snug is not specific to the Plastibell circumcision technique. It is a general care tip for all newborns.
Choice B rationale
While it’s important to monitor the circumcision site for signs of infection, a dark red tip of the penis is not a specific concern related to the Plastibell circumcision technique.
Choice C rationale
Yellow exudate, which is a normal part of the healing process, will form at the surgical site within 24 hours. This is a normal part of the healing process and should not be mistaken for pus, which would indicate an infection.
Choice D rationale
The Plastibell device is not removed 4 hours after the procedure. Instead, it falls off naturally after about a week.

A. Provide oxygen to the client via a nonrebreather face mask. B. Administer oxytocin to the client. C. Empty the client’s bladder. D. Massage the client’s fundus.

Correct Answer is D

Explanation

Choice A rationale
Providing oxygen to the client via a nonrebreather face mask is important if the client shows signs of hypoxia or shock due to blood loss. However, it is not the first action the nurse should take.
Choice B rationale
Administering oxytocin to the client can help contract the uterus and control bleeding, but it is not the first action the nurse should take.
Choice C rationale

Emptying the client’s bladder can help the uterus contract more effectively, but it is not the first action the nurse should take.
Choice D rationale
The first action the nurse should take when noting excessive vaginal bleeding is to massage the client’s fundus. A boggy uterus can lead to excessive bleeding, and massaging the fundus helps the uterus contract and can control the bleeding.

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A nurse is assessing a full-term newborn upon admission to the nursery. What clinical findings should the nurse report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is educating the parents of a newborn about the Plastibell circumcision technique. Which piece of information should the nurse include?

Correct Answer is C

Explanation

A nurse is assessing a client who is 1 hour postpartum following a vaginal birth. The nurse notes that the client has excessive vaginal bleeding. What action should the nurse take first?

Correct Answer is D

Explanation

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