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?

Single palmar creases.

Rust-stained urine.

Transient circumoral cyanosis.

Subconjunctival hemorrhage.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A. Single palmar creases.

Choice A rationale: Single palmar creases (also known as simian creases) can be associated with certain genetic conditions, such as Down syndrome. The presence of this finding in a newborn should prompt further investigation and reporting to the healthcare provider for additional assessment and possible genetic testing.

Choice B rationale: Rust-stained urine in a newborn is typically caused by uric acid crystals, which are common and not considered abnormal during the first few days of life. This condition usually resolves without intervention, and it does not require reporting to the provider unless it persists or is accompanied by other symptoms.

Choice C rationale: Transient circumoral cyanosis is a common finding in newborns, especially when crying or feeding. It usually resolves on its own and is not considered an alarming sign unless it persists or is associated with central cyanosis or other signs of respiratory distress.

Choice D rationale: Subconjunctival hemorrhage is a common finding in newborns, usually resulting from the pressure changes during delivery. It typically resolves on its own within a few weeks and does not require reporting to the provider unless there are signs of other underlying conditions.

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Correct Answer is A

Explanation

Nägele’s Rule is a standard way of calculating the due date for a pregnancy. The rule estimates the expected date of delivery (EDD) by adding one year, subtracting three months, and adding seven days to the first day of a woman’s last menstrual period (LMP).

So, if the last menstrual cycle started on June 21, here’s how you calculate:

Subtract 3 months from June 21, which gives you March 21.
Add 7 days to March 21, which gives you March 28.
Add 1 year to the current year.

So, the estimated date of delivery in the next year would beMarch 28.

A. The client is changing the perineal pad once daily. B. The client is using witch hazel pads on the perineum. C. The client cleans the perineum with a squeeze bottle after urinating. D. The client's perineal suture line is well-approximated.

Correct Answer is A

Explanation

Choice A rationale:
Changing the perineal pad once daily could lead to infection, which would delay wound healing.
Choice B rationale:
Witch hazel pads are often used for their soothing and anti-inflammatory properties, which can aid in healing.
Choice C rationale:
Cleaning the perineum with a squeeze bottle after urinating helps to keep the area clean and promote healing.
Choice D rationale:
A well-approximated suture line indicates that the wound edges are close together, which is conducive to healing.

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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

A nurse is calculating the estimated date of birth using Nägele's rule for a client who is pregnant and whose last menstrual cycle started June 21. Which of the following is the estimated date of delivery in the next year?

Correct Answer is A

Explanation

A nurse is caring for a client who is postpartum and has a perineal laceration. Which of the following findings places the client at risk for delayed wound healing?

Correct Answer is A

Explanation

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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?