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?
Bluish discoloration of the hands and feet.
Overlapping of the cranial bones.
Forward and lateral positioning of the ears.
Small, distended white sebaceous glands on the face.
The Correct Answer is C
The correct answer is Choice C.
Choice A rationale: Bluish discoloration of the hands and feet (acrocyanosis) is common in newborns and usually resolves within the first few days of life. It is not typically a priority unless it persists or is accompanied by other signs of distress.
Choice B rationale: Overlapping of the cranial bones (craniosynostosis) requires monitoring but is not an immediate priority unless there are signs of increased intracranial pressure.
Choice C rationale: Forward and lateral positioning of the ears can be indicative of certain genetic conditions, such as Down syndrome. This finding is significant as it can signal the need for further evaluation and intervention to address any associated health concerns.
Choice D rationale: Small, distended white sebaceous glands on the face (milia) are common in newborns and resolve on their own without intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Intense contractions lasting 45 to 60 seconds are normal during labour and indicate effective uterine activity. This finding does not warrant immediate reassessment.
Choice B rationale:
Progressive sacral discomfort during contractions can be a normal part of labour as the baby descends into the birth canal. It does not necessarily indicate a need for reassessment.
Choice C rationale:
A sense of excitement and warm, flushed skin can be a common emotional and physiological response during labour, particularly as the woman reaches the final stages of delivery. This finding does not necessarily require immediate reassessment.
Choice D rationale:
"An urge to have a bowel movement during contractions”. is the correct answer because it could be an indication that the client is experiencing the urge to push, which means the baby's head is descending and nearing delivery. The nurse should reassess the client promptly to determine if she is fully dilated and ready to push.
Correct Answer is D
Explanation
Choice A rationale:
This statement is incorrect. An indirect Coombs' test is not used to determine the risk of hypoglycemia in a baby after birth. It is used to detect antibodies against red blood cells, particularly in the context of blood incompatibility between a pregnant woman and her fetus.
Choice B rationale:
This statement is incorrect. An indirect Coombs' test is not related to determining the amount of amniotic fluid around the fetus. It is used primarily to assess for Rh incompatibility between the mother and fetus.
Choice C rationale:
This statement is incorrect. The test described here is a Doppler ultrasound, not an indirect Coombs' test. Doppler ultrasound is used to study blood flow in the fetus and placenta using ultrasound waves.
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