A nurse is assessing a newborn who is 4 hr. old. Which of the following findings should the nurse identify as the priority to report to the provider?

Overlapping of the cranial bones

Small, distended white sebaceous glands on the face

Forward and lateral positioning of the ears

Bluish discoloration of the hands and feet

Answer and Explanation

The Correct Answer is D

In a newborn, bluish discoloration of the hands and feet may indicate a condition called peripheral cyanosis, which suggests poor oxygenation. It is important to report this finding to the healthcare provider promptly, as it may indicate a respiratory or circulatory problem that requires immediate attention.

Option a) Overlapping of the cranial bones is a common finding in newborns due to the molding of the head during delivery. This is not a priority finding to report unless there are other signs of concern, such as abnormal head shape or signs of trauma.

Option b) Small, distended white sebaceous glands on the face are called milia and are a normal finding in newborns. They are not a priority finding to report and typically resolve on their own within a few weeks.

Option c) Forward and lateral positioning of the ears is a normal finding in a newborn and is not a priority to report. The ears may appear folded or positioned diﬀerently due to the pressure and positioning in the womb.

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Correct Answer is A

Explanation

The appropriate response by the nurse is to reassure the client that the discharge is common during the first 24 to 72 hours following a circumcision. This discharge is typically a mixture of blood and serum and is a normal part of the healing process. It is important to provide accurate and reassuring information to alleviate any concerns the client may have.

Option b) "I will need to obtain a sample of the discharge for laboratory testing" is not necessary in this situation. The yellow discharge described by the client is a common and expected occurrence following a circumcision, and routine laboratory testing is not required.

Option c) "Wipe the discharge away gently with a washcloth and warm water for the next 48 hours" is not the recommended approach. It is generally advised to avoid wiping or manipulating the circumcision site during the healing process to prevent irritation or disruption of the healing tissues.

Option d) "Apply povidone-iodine solution twice daily to the circumcision site" is not recommended. Povidone-iodine solution is not typically used for routine care of a circumcision site. It is important to follow the healthcare provider's instructions regarding post-circumcision care, which usually involves keeping the area lean and dry without the use of any specific solutions or ointments.

A. This infection requires that airborne precautions be initiated for the newborn. B. Mothers will receive prophylactic treatment with acyclovir prior to delivery. C. Lesions are visible on the mother's genitals. D. Transmission can occur via the saliva and urine of the newborn.

Correct Answer is D

Explanation

This is the only option that is true and relevant to maternal cytomegalovirus infection. CMV can be transmitted from the newborn to the mother or other caregivers through contact with the saliva and urine of the newborn, which may contain high amounts of the virus. Therefore, it is important to practice good hygiene and avoid contact with these body ﬂuids when caring for a newborn with congenital CMV.

a) This infection does not require that airborne precautions be initiated for the newborn. Airborne precautions are used to prevent the spread of infections that are transmitted by small droplets that can remain suspended in the air and travel over long distances, such as tuberculosis, measles, or chickenpox. CMV is not transmitted by airborne route, and standard precautions are sufficient to prevent exposure to blood or body ﬂuids that may contain CMV
b) Mothers will not receive prophylactic treatment with acyclovir prior to delivery. Acyclovir is an antiviral medication that is used to treat herpes simplex virus (HSV) infections, such as cold sores, genital herpes, or neonatal herpes. It has no eﬀect on CMV infection, and it is not recommended for pregnant women or newborns with CMV.
c) Lesions are not visible on the mother's genitals. Lesions are a sign of HSV infection, not CMV infection. HSV can cause painful blisters or ulcers on the mouth or genitals, and it can be transmitted to the newborn during delivery. CMV does not cause any visible symptoms on the mother's genitals, and it can be transmitted to the newborn during pregnancy, delivery, or breastfeeding.

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A nurse is assessing a newborn who is 4 hr. old. Which of the following findings should the nurse identify as the priority to report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who reports that her baby has yellow discharge forming at the circumcision site. Which of the following is an appropriate response by the nurse?

Correct Answer is A

Explanation

A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching?

Correct Answer is D

Explanation

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