A nurse is assessing a newborn on the first day of life. Which of the following is an expected finding? (Select All that Apply.)
Fusion of labia in female genitalia
Erythema toxicum on newborn's skin
Hypospadias is noted in the male newborn
Presence of syndactyly in extremities
Negative Ortolani sign
Correct Answer : B,E
A) Fusion of labia in female genitalia:
Fusion of the labia in a female newborn is not an expected finding. This could indicate a condition such as labial adhesion or an abnormality in the development of the genitalia. Normally, the labia in a female newborn are separated. Any signs of fusion would require further evaluation by the healthcare provider.
B) Erythema toxicum on newborn's skin:
Erythema toxicum is a common and expected finding in newborns, usually appearing within the first 2–3 days of life. It consists of small, red papules or pustules on a red base, often described as a "flea-bitten" appearance. This rash is benign and resolves on its own within a few days to weeks. It is not associated with any infection or underlying health issues.
C) Hypospadias is noted in the male newborn:
Hypospadias, a condition where the urethral opening is located on the underside of the penis rather than at the tip, is not an expected finding in all newborn males. While it occurs in a small percentage of male infants, it is a congenital anomaly that would require further assessment and possibly surgical correction. It is not considered a normal finding in a newborn.
D) Presence of syndactyly in extremities:
Syndactyly, the condition where two or more fingers or toes are fused together, is not a normal finding in newborns. While it is a congenital anomaly that can occur in some infants, it is not expected and requires further evaluation and possibly surgical intervention depending on the severity.
E) Negative Ortolani sign:
A negative Ortolani sign is an expected and normal finding in a newborn. The Ortolani maneuver is used to assess for hip dislocation, and a negative result indicates that the hip is stable and not dislocated. If the Ortolani sign were positive, it would suggest the presence of a developmental hip dysplasia, which would require further diagnostic evaluation. A negative sign is considered typical and reassuring.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
Given:
Desired dose: Ampicillin 0.5 g PO
Available concentration: Ampicillin capsules 250 mg each
To find:
Number of capsules to administer for a single dose
Step 1: Convert desired dose to milligrams
We know that 1 gram (g) is equal to 1000 milligrams (mg). Therefore, to convert the desired dose from grams to milligrams, we multiply by 1000:
Desired dose (mg) = Desired dose (g) x 1000
Desired dose (mg) = 0.5 g x 1000 = 500 mg
Step 2: Calculate the number of capsules
To find the number of capsules, we divide the desired dose by the strength of each capsule:
Number of capsules = Desired dose / Capsule strength
Number of capsules = 500 mg / 250 mg/capsule = 2 capsules
Correct Answer is B
Explanation
A) Decrease the client's IV fluids:
Sinusoidal fetal heart rate patterns are concerning and typically indicate severe fetal distress, which is often associated with conditions such as fetal anemia, hypoxia, or central nervous system (CNS) damage. Decreasing IV fluids is not an appropriate response to a sinusoidal pattern. The primary focus should be on fetal well-being, not fluid management, in this situation.
B) Prepare the client for an emergent birth:
This pattern is typically associated with severe fetal compromise and is an ominous sign. Immediate intervention is required, and emergent delivery may be necessary to prevent further fetal distress and potential harm. The nurse should promptly notify the healthcare provider and prepare the client for an emergency cesarean delivery or other urgent interventions.
C) Turn the client to a supine position:
The supine position is not recommended for managing fetal distress, as it may decrease uterine blood flow and worsen the situation, especially if the fetus is experiencing hypoxia. The appropriate intervention for addressing a sinusoidal heart rate pattern is not repositioning the client in a supine position, but rather preparing for emergency delivery and providing immediate support to stabilize both mother and fetus.
D) Document the findings:
While it is important to document any fetal heart rate pattern, sinusoidal patterns require immediate action. Documentation alone is not sufficient in this case, as it does not address the potential life-threatening situation for the fetus. The nurse should not delay action, and the focus should be on preparing for emergency birth and notifying the healthcare provider immediately.
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