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A nurse is caring for a newborn 4 hours after their birth. Which of the following findings should the nurse report to the provider?

A.

Pale blue hands and feet

B.

Soft grunting noises with respiration

C.

Blood-tinged discharge from the vagina

D.

Positive Babinski reflex

Answer and Explanation

The Correct Answer is B

A. Pale blue hands and feet (acrocyanosis) are normal during the first 24 hours after birth.
B. Soft grunting noises can indicate respiratory distress and should be reported promptly.
C. Blood-tinged vaginal discharge (pseudomenstruation) is normal in newborn females due to maternal hormones.
D. A positive Babinski reflex is a normal neurologic finding in newborns.


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Related Questions

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

Explanation

Statement

Include

Not Include

"Your baby needs to be repositioned every 2 to 3 hours while under the lights."

✅

"Your baby's eyes will be covered with an eye shield during therapy."

✅

"Avoid applying lotion to your baby's skin."

✅

"Keep a hat on your baby during treatment."

✅

"We will give your baby glucose water between breast feedings.

✅

"Bilirubin is primarily excreted through the stool."

✅

The treatment lights can cause a transient skin rash on your baby."

✅

The treatment lights emit a significant amount of ultraviolet radiation.

✅

  • Repositioning every 2 to 3 hours exposes different skin areas to light, enhancing bilirubin breakdown and preventing pressure sores.
  • Eye shields protect the newborn’s eyes from damage caused by bright phototherapy lights.
  • Avoiding lotion prevents skin irritation or burns and ensures effective light penetration during treatment.
  • Keeping a hat on blocks light exposure to the scalp, reducing the effectiveness of phototherapy.
  • Glucose water is not recommended; feeding with breast milk or formula helps promote bilirubin elimination through stools.
  • Bilirubin is mainly excreted through the stool after being converted into a water-soluble form by phototherapy.
  • Phototherapy can cause a mild, temporary rash, which is harmless but important to inform parents about.
  • Phototherapy lights emit blue light, not harmful ultraviolet radiation, making them safe for newborn treatment.

Correct Answer is ["A","B"]

Explanation

  • Oral temperature 38.3°C (101°F)
    Elevated temperature indicates maternal fever, which could suggest infection such as chorioamnionitis, especially concerning with ruptured membranes.
  • HGB 10 g/dL (normal > 11 g/dL)
    Low hemoglobin indicates anemia, which could compromise oxygen delivery to the fetus and affect maternal health during labor.

Explanation for non-highlighted findings:

  • Heart rate 98/min: Slightly elevated but within normal range for labor.
  • Blood pressure 112/59 mm Hg: Normal blood pressure for pregnancy.
  • Uterine contractions every 3 mins moderate to palpation: Normal pattern for active labor.

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