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A nurse is assisting with the care of a newborn who was born at 39 weeks of gestation and is 36 hr old.

Assessment

Fontanels soft and flat

Head molded with caput succedaneum

Eyes symmetric, no discharge, sclera yellow Mucous membranes dry

Abdomen soft and rounded, bowel sounds present x 4 quadrants

Which of the following findings should the nurse report to the RN7 Select all that apply.

Glucose level

Mucous membrane assessment

Respiratory rate

Sclera color

Intake and output

Coombs test result

Heart rate

Head assessment finding

Answer and Explanation

Correct Answer : B,D,F,H

A) Glucose level might need to be assessed if there are signs of hypoglycemia or other concerns.
B) Mucous membrane assessment: Dry mucous membranes might indicate dehydration or other issues that need further evaluation.
C. Respiratory rate: The respiratory rate is not provided in the assessment, so there's no basis to report it. The assessment did not mention any abnormal respiratory rate.
D) The sclera color indicates that the newborn has jaundice, which is a common condition in newborns but requires monitoring and treatment to prevent complications.
E. Intake and output: Intake and output are not mentioned in the assessment, so there's no basis to report it. This information is not provided in the assessment findings.
F) The Coombs test result is important for assessing the presence of antibodies that could lead to hemolytic disease of the newborn due to blood type incompatibility with the mother, which can also cause jaundice and other serious problems.
G. Heart rate: The heart rate is not mentioned in the assessment, so there's no basis to report it. The assessment did not mention any abnormal heart rate.
H) Head assessment findings, such as soft and flat fontanels along with a molded head, should be communicated for further evaluation. The head assessment finding of caput succedaneum is a swelling of the scalp caused by pressure during delivery, which usually resolves within a few days but can increase the risk of jaundice and infection.

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Correct Answer is D

Explanation

The correct answer is d. "I may develop discoloration on my cheeks from hormonal changes."

Choice a rationale:

Statement:"I should expect to have burning when I urinate during the third trimester."
Rationale:This statement is incorrect.Burning during urination is not a normal physiological change of pregnancy.It may be a sign of a urinary tract infection (UTI),which is a common infection during pregnancy.If a pregnant client experiences burning during urination,she should report it to her healthcare provider for evaluation and treatment.

Choice b rationale:

Statement:"I may have an infection if I develop a dark line in the middle of my abdomen."
Rationale:This statement is incorrect.A dark line in the middle of the abdomen,known as the linea nigra,is a normal physiological change of pregnancy.It is caused by hormonal changes that increase melanin production in the skin.The linea nigra typically appears in the second trimester and fades after delivery.

Choice c rationale:

Statement:"I should expect my fingers and face to be swollen."
Rationale:This statement is partially correct.Some swelling in the hands and face is common during pregnancy,especially in the third trimester.This is due to fluid retention caused by hormonal changes.However,excessive swelling,particularly in the hands and face,can be a sign of preeclampsia,a serious pregnancy complication.It's important to report any significant swelling to a healthcare provider.

Choice d rationale:

Statement:"I may develop discoloration on my cheeks from hormonal changes."
Rationale:This statement is correct.Hormonal changes during pregnancy can cause a variety of skin changes,including melasma,which is a brownish discoloration that often appears on the cheeks,forehead,and nose.Melasma is more common in women with darker skin tones and usually fades after delivery.

A. "I should elevate my baby's head on a cushion when she is sleeping" B. "I should replace the batteries in my smoke detector twice per year." C. "I should set my hot water heater to 130 degrees Fahrenheit. D. "I should use baby powder with each diaper change

Correct Answer is B

Explanation

A) Incorrect- Elevating a baby's head with a cushion during sleep is not recommended, as it can increase the risk of sudden infant death syndrome (SIDS) and obstructed breathing.
B) Correct - "I should replace the batteries in my smoke detector twice per year." Regularly replacing smoke detector batteries helps ensure they function properly in case of a fire emergency.
C) Incorrect- Setting the hot water heater to 130°F (54.4°C) is too hot and can cause scalding burns. The recommended temperature is 120°F (48.9°C) or lower.
D) Incorrect- Baby powder is not recommended for use with diaper changes, as it can be inhaled by the baby and lead to respiratory issues.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a prenatal clinic is reinforcing teaching with a client about expected physiological changes during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is assisting with a prenatal class discussion about newborn safety. Which of the following statements by a participant indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse in an antepartum clinic is reinforcing teaching with a client who is pregnant and has a new prescription for oral ferrous sulfate. Which of the following statements by the client indicates an understanding of the teaching?

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