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 A

Explanation

Choice A rationale
Asking if the client’s back labor has improved is a good way to evaluate the effectiveness of the hands-and-knees position. This position has been shown to reduce persistent back pain in laboring women with a fetus in the occipitoposterior position.
Choice B rationale

Feeling relief from pelvic pressure is not specifically associated with the hands-and-knees position.
Choice C rationale
Lessening of suprapubic pain is not specifically associated with the hands-and-knees position.
Choice D rationale
Contractions feeling further apart is not a specific outcome associated with the hands-and- knees position.

A. Prepare for surgical closure after 72 hours. B. Cleanse the site with povidone-iodine. C. Monitor the rectal temperature every 4 hours. D. Administer broad-spectrum antibiotics.

Correct Answer is D

Explanation

Choice A rationale
While surgical closure is a common treatment for myelomeningocele, it is not typically performed immediately after birth.
Choice B rationale
Cleansing the site with povidone-iodine is not typically the first step in caring for a newborn with a myelomeningocele.
Choice C rationale
Monitoring the rectal temperature every 4 hours is not specifically related to the care of a newborn with a myelomeningocele.
Choice D rationale
This is the correct answer. Administering broad-spectrum antibiotics can help prevent infection in a newborn with a myelomeningocele.

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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 caring for a client who is in active labor with a fetus in the occipitoposterior position. The nurse assists the client into a hands-and-knees position.Which of the following Questions should the nurse ask to evaluate the effectiveness of this intervention?

Correct Answer is A

Explanation

A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?

Correct Answer is D

Explanation

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

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A nurse is helping a provider administer a dinoprostone insert to induce labor in a client. What action should the nurse take?

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