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
Transient circumoral cyanosis
Single palmar creases
Subconjunctival hemorrhage
The Correct Answer is C
A. Rust-stained urine: This is a common finding in newborns and is due to urate crystals in the urine. It is benign and typically resolves as the infant's kidney function matures.
B. Transient circumoral cyanosis: This is a common finding in newborns, particularly during crying or feeding, and it usually resolves on its own. It does not typically indicate a serious condition.
C. A single palmar crease (also known as a simian crease) can be a normal variant, but it is often associated with certain congenital anomalies or chromosomal disorders, such as Down syndrome. The nurse should report this finding to the provider for further evaluation and possible genetic testing.
D. Subconjunctival hemorrhage: This can occur during delivery due to the pressure of vaginal birth. It is harmless and usually resolves within a few weeks without treatment.
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Related Questions
Correct Answer is B
Explanation
The client who is at 34 weeks of gestation and is experiencing epigastric pain and headache should be assessed first. These symptoms may indicate preeclampsia, which is a serious pregnancy complication characterized by high blood pressure and organ damage. The nurse should monitor the client's blood pressure and assess for signs of organ damage, such as proteinuria, visual disturbances, and epigastric or right upper quadrant pain. The other clients may also require assessment and intervention, but their symptoms are less urgent and may indicate less serious conditions, such as a urinary tract infection (painful urination), early pregnancy symptoms (nausea and vomiting), or early labor (cramping and spotting).
Correct Answer is D
Explanation
This
suggests that the nurse should assess the newborn's latch while breastfeeding. Sore nipples are a common concern among breastfeeding mothers, and the most common cause is an improper latch. The nurse should ensure that the baby is latching on correctly and not causing trauma to the mother's nipples. A proper latch involves the baby taking in a good portion of the areola and not just the nipple. Assessing the newborn's latch can help identify any issues with the baby's mouth or tongue that may be causing difficulty latching on. If the baby is not latching correctly, the nurse can provide education and support to help the mother correct the issue. Offering supplemental formula between feedings (choice A) is not recommended as it can decrease the frequency of breastfeeding and reduce the stimulation for milk production, leading to decreased milk supply. Instructing the client to wait 4 hours between daytime feedings (choice C) is not recommended as it can decrease milk production and lead to inadequate nutrition for the newborn.
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