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?
Transient circumoral cyanosis
Single palmar creases
Rust-stained urine
Subconjunctival hemorrhage
The Correct Answer is B
A. Transient circumoral cyanosis: This is a common finding in newborns and typically resolves without treatment.
B. The nurse should report the finding of "Single palmar creases" to the provider. Single palmar creases, also known as a single transverse palmar crease or simian crease, are associated with certain genetic syndromes like Down syndrome. It can be a significant clinical finding that warrants further evaluation and potential genetic testing to rule out any underlying conditions.
C. Rust-stained urine: This can occur due to the breakdown of red blood cells in the newborn's body during the first few days of life. It's usually benign and resolves on its own.
D. Subconjunctival hemorrhage: This is a common finding caused by pressure during childbirth and is typically benign, resolving without intervention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Placing the client in a semi-Fowler's position for 1 hr after administration: While positioning can be important for some procedures, it is not a standard requirement for the administration of dinoprostone.
B. The nurse should verify that informed consent is obtained prior to the administration of any medication, including dinoprostone for labor induction. Informed consent is a legal and ethical requirement to ensure that the client understands the risks and benefits of the procedure or medication and gives their voluntary agreement.
C. Allowing the medication to reach room temperature prior to administration: The temperature of the medication is not typically a consideration for dinoprostone administration.
D. Instructing the client to avoid urinary elimination until after administration: This is not a standard requirement for dinoprostone administration, and it is important to encourage normal urinary elimination to prevent complications like urinary tract infections.
Correct Answer is A
Explanation
A. Covering the exposed umbilical cord with a sterile, warm, saline-soaked towel helps prevent compression and drying of the cord. This can temporarily relieve pressure on the cord until more definitive interventions, such as a cesarean section, can be performed.
B. Administering oxygen via a nonrebreather mask is important but is not the first action to take. It should be done after covering the cord and ensuring adequate oxygenation for both the mother and the fetus.
C. Initiating an IV infusion is also important but not the first priority when there is a prolapsed cord. The priority is to relieve cord compression and restore fetal oxygenation.
D. Performing a vaginal examination by applying upward pressure on the presenting part can be harmful in this situation as it may push the presenting part further down and worsen cord compression. It should not be performed until the cord is covered and the situation is stabilized.
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