A nurse is assessing a newborn following a vaginal birth. Which of the following findings should the nurse identify as requiring follow-up? (Select All that Apply.)

Presence of a two-vessel umbilical cord

Molding of the skull

Asymmetry of ears

Tongue extending past the lower

Diminished breath sounds on one side

Answer and Explanation

Correct Answer : A,C,E

A) Presence of a two-vessel umbilical cord:
The presence of a two-vessel umbilical cord (instead of the normal three vessels, which includes two arteries and one vein) is a significant finding that requires follow-up. A two-vessel cord can be associated with fetal anomalies, particularly with renal, cardiac, or chromosomal conditions. Therefore, it requires further evaluation to rule out any underlying conditions and ensure proper organ development.

B) Molding of the skull:
Molding of the skull is a normal and expected finding in newborns following a vaginal birth, especially after a long or difficult delivery. It refers to the temporary reshaping of the fetal skull bones as they overlap to pass through the birth canal. This is typically self-correcting and resolves within a few days, so no follow-up is needed for molding.

C) Asymmetry of ears:
Asymmetry of the ears can indicate congenital anomalies, such as craniofacial syndromes or other physical deformities. Although some degree of asymmetry can occur in newborns, especially in the first hours of life, persistent or significant asymmetry should be evaluated further. It may indicate an abnormality that requires follow-up or assessment by a specialist.

D) Tongue extending past the lower lip:
A tongue that extends past the lower lip is a normal finding in newborns, as babies are still developing their oral reflexes and muscle tone. This is not a cause for concern, and no follow-up is required unless other feeding issues arise. It's important to differentiate between normal tongue movements and more serious concerns like tongue-tie (ankyloglossia), but this is not indicative of a problem by itself.

E) Diminished breath sounds on one side:
Diminished breath sounds on one side of the chest can indicate a serious issue, such as a pneumothorax, diaphragmatic hernia, or other respiratory concerns. This finding warrants immediate follow-up, as the newborn could be experiencing a respiratory distress condition that needs urgent intervention and management. This is a significant finding requiring immediate evaluation.

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Correct Answer is C

Explanation

A) Dry and stimulate newborn with towel:
Drying and stimulating the newborn immediately after birth is a standard practice to prevent heat loss and promote early bonding. This action helps to prevent heat loss through evaporation and stimulates the newborn to breathe. It is an appropriate intervention to reduce the risk of hypothermia, not increase it.

B) Place a hat on the newborn's head:
Placing a hat on the newborn’s head is an appropriate and helpful intervention. Since a significant amount of heat is lost through the head, especially in newborns who have a larger surface area relative to their body mass, keeping the head covered with a hat helps to retain warmth and reduce the risk of hypothermia. This would not place the newborn at risk for hypothermia.

C) Maintain the delivery room temperature at 20° C (68° F):
A delivery room temperature of 20° C (68° F) is on the lower end of the recommended range for newborn care. Newborns are particularly susceptible to heat loss due to their high surface area-to-body weight ratio and immature thermoregulation system. A cooler environment like 20°C increases the risk of hypothermia, as the newborn will lose heat more quickly than it can generate on its own.

D) Place a blanket on top of maternal and newborn:
Placing a blanket over the mother and newborn is an appropriate intervention to prevent heat loss. This promotes warmth by reducing heat loss from the newborn's body surface to the cooler environment. This would not place the newborn at risk for hypothermia; instead, it helps to maintain body temperature.

A. Apply petrolatum to penis with each diaper change B. Use a diaper barrier cream that contains zinc oxide C. Use alcohol-based baby wipes on the soiled genital area D. Fold the diaper below the umbilical cord at all times E. Apply alcohol to the umbilical stump with a diaper change F. Use a soft-bristled brush with mild shampoo to wash the head G. Bathe in a shallow warm tub every other day H. Cover the hands with socks or sleeves at all times I. Apply mildly scented lotion to face as needed

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"},"G":{"answers":"B"},"H":{"answers":"B"},"I":{"answers":"B"}}

Explanation

Apply petrolatum to penis with each diaper change: Applying petrolatum prevents the healing circumcision site from adhering to the diaper, reducing pain and promoting proper healing.
Use a diaper barrier cream that contains zinc oxid: Zinc oxide is used for diaper rash treatment but is not routinely necessary. It may interfere with circumcision healing by creating a barrier that retains moisture.
Use alcohol-based baby wipes on the soiled genital area: Alcohol-based wipes can be too harsh on a newborn’s delicate skin and may cause irritation, especially on the healing circumcision site.
Fold the diaper below the umbilical cord at all times: Folding the diaper below the umbilical cord keeps the area dry and exposed to air, promoting natural drying and reducing the risk of infection.
Apply alcohol to the umbilical stump with a diaper change: Alcohol was previously used to dry the cord, but current guidelines recommend keeping it clean and dry, allowing it to fall off naturally.
Use a soft-bristled brush with mild shampoo to wash the head: A soft-bristled brush helps loosen cradle cap (seborrheic dermatitis), preventing buildup of flaky skin without causing irritation.
Bathe in a shallow warm tub every other day: Full immersion bathing should be avoided until the umbilical cord stump falls off to prevent moisture retention and infection. Sponge baths are recommended instead.
Cover the hands with socks or sleeves at all times: While covering hands temporarily can prevent scratches, prolonged covering may interfere with newborn sensory development and exploration.
Apply mildly scented lotion to face as needed: Newborn skin is sensitive, and scented lotions may cause irritation or allergic reactions. If needed, only fragrance-free moisturizers should be used.

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A nurse is assessing a newborn following a vaginal birth. Which of the following findings should the nurse identify as requiring follow-up? (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has their newborn placed skin to skin immediately following birth with a temperature of 37° C (98.6" F). Which of the following interventions by the nurse would place the newborn at higher risk for hypothermia?

Correct Answer is C

Explanation

A nurse is assisting in the care of a newborn. Exhibits A nurse is reinforcing discharge education with the parents of a newborn. For each potential point, click to specify if the teaching is anticipated or contraindicated for the newborn.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"},"G":{"answers":"B"},"H":{"answers":"B"},"I":{"answers":"B"}}

Explanation

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