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

Answer and Explanation

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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Correct Answer is B

Explanation

The correct answer is choice B, "Allow the baby to feed at least every 3 hr." The nurse should instruct the client who is breastfeeding her newborn to allow the baby to feed at least every 3 hr, which can help to establish an adequate milk supply. The client should also be instructed to feed the newborn on demand, offer both breasts at each feeding, and continue to breastfeed for as long as the baby is interested. The nurse should advise the client to expect at least six to eight wet diapers every 24 hr and monitor the newborn for signs of dehydration, such as a decrease in urine output, dry mucous membranes, or lethargy.

A. Progressive sacral discomfort during contractions B. Intense contractions lasting 45 to 60 seconds C. An urge to have a bowel movement during contractions D. A sense of excitement and warm, flushed skin

Correct Answer is C

Explanation

A. Discomfort in the lower back (sacral area) is common during labor, particularly during contractions. This is not an unusual finding that would require immediate reassessment.

B. Contractions lasting between 45 to 60 seconds are typical during the active phase of labor. This duration of contractions is expected as labor progresses, and does not require immediate reassessment.

C. This sensation can indicate that the fetus has descended into the birth canal and may be a sign that the client is entering the second stage of labor, or is close to delivery. This requires immediate reassessment by the nurse to check for full cervical dilation and fetal descent.

D. Emotional excitement and changes in skin temperature are typical responses during labor due to the physiological and emotional aspects of childbirth. This does not indicate the need for immediate reassessment.

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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 providing discharge instructions to a client who is breastfeeding her newborn. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

A nurse is caring for a client who is in labor. Which of the following findings should prompt the nurse to reassess the client?

Correct Answer is C

Explanation

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