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

Rust-stained urine.

Single palmar creases.

Subconjunctival hemorrhage.

Transient circumoral cyanosis.

Answer and Explanation

The Correct Answer is B

The correct answer is choice B. Single palmar creases.

Choice A rationale:

Rust-stained urine is typically due to urate crystals and is common in newborns. It usually resolves on its own and is not a cause for concern.

Choice B rationale:

Single palmar creases can be associated with certain genetic conditions, such as Down syndrome. This finding should be reported to the provider for further evaluation.

Choice C rationale:

Subconjunctival hemorrhage is a common finding in newborns due to the pressure changes during delivery. It usually resolves without intervention and is not typically a cause for concern.

Choice D rationale:

Transient circumoral cyanosis is often seen in newborns and can occur when the baby is crying or feeding. It usually resolves on its own and is not typically a cause for concern.

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Correct Answer is B

Explanation

Choice A rationale:

A client with placenta previa and a hematocrit of 36% should be monitored closely due to the risk of bleeding, but it is not an immediate priority compared to the client with hyperemesis gravidarum and a low sodium level.

Choice B rationale:

Hyperemesis gravidarum is a severe form of morning sickness characterized by excessive vomiting, leading to dehydration and electrolyte imbalances. A sodium level of 110 mEq/L is dangerously low and requires immediate attention to correct the electrolyte disturbance and prevent further complications.

Choice C rationale:

A client with diabetes mellitus and an HbA1c of 5.8% is within a normal range, indicating good glycemic control. This client's condition can be managed on an outpatient basis and does not require urgent assessment compared to the others.

Choice D rationale:

A client with preeclampsia and a creatinine level of 1.1 mg/dL should be closely monitored, but it is not the priority over the client with hyperemesis gravidarum and severe electrolyte imbalance.

A. Place the client in a semi-Fowler's position for 1 hr after administration. B. Instruct the client to avoid urinary elimination until after administration. C. Verify that informed consent is obtained prior to administration. D. Allow the medication to reach room temperature prior to administration.

Correct Answer is C

Explanation

The correct answer is choice C: Verify that informed consent is obtained prior to administration. Choice A rationale: Placing the client in a semi-Fowler’s position is not specifically related to the administration of dinoprostone. This position is often used post-administration to promote comfort and labor progression, but it is not a required action prior to the administration of dinoprostone. Choice B rationale: Instructing the client to avoid urinary elimination until after administration is not necessary. There is no evidence to suggest that retaining urine affects the efficacy or safety of dinoprostone administration. Choice C rationale: Verifying that informed consent is obtained prior to administration is crucial. Dinoprostone, like any medication used to induce labor, carries potential risks and side effects. It is essential that the client is informed about these risks and consents to the procedure before the medication is administered. Choice D rationale: Allowing the medication to reach room temperature prior to administration is not a standard requirement for dinoprostone inserts. Medications have specific storage and administration guidelines that should be followed according to the manufacturer’s instructions and facility protocols.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A nurse is assisting the provider to administer a dinoprostone insert to induce labor for a client. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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