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A nurse is caring for a newborn 8 hours of age.Which of the following assessment findings require follow-up by the nurse?

A.

Large ecchymotic caput succedaneum noted on posterior scalp.

B.

Yellow discoloration noted of sclera and oral mucosa.

C.

Fontanel level and soft.

D.

Respiratory rate 78/min.

Answer and Explanation

Correct Answer : A,B,D

Choice A rationale

A large ecchymotic caput succedaneum, which is swelling of the scalp due to birth trauma, usually resolves within a few days. However, its large size and presence of bruising should be monitored for potential complications such as jaundice.

Choice B rationale

Yellow discoloration of the sclera and oral mucosa indicates jaundice, which can be due to hyperbilirubinemia. This condition requires follow-up and possible treatment to prevent severe complications.

Choice C rationale

A level and soft fontanel in a newborn is a normal finding. It does not require follow-up as it indicates that intracranial pressure is normal.

Choice D rationale

A respiratory rate of 78/min in a newborn is significantly higher than the normal range (30-60/min). This finding requires follow-up to assess for respiratory distress or other underlying conditions.


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Related Questions

Correct Answer is B

Explanation

Choice A rationale

Herbal tea is not scientifically proven to reduce breast engorgement and may not be effective.

Choice B rationale

Warm compresses applied before feeding help to soften the breasts, making it easier for the baby to latch and reducing engorgement.

Choice C rationale

Letting the baby drain one breast completely at each feeding can help prevent engorgement but is not specifically for managing existing engorgement.

Choice D rationale

Feeding every 3-4 hours may not be frequent enough to prevent engorgement, especially in the early days of breastfeeding.

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

Explanation

  1. Jitteriness: This can be a sign of hypoglycemia in a newborn, and it may also be seen in Neonatal Abstinence Syndrome (NAS) due to withdrawal symptoms.
  2. Lethargy: Lethargy is common in hypoglycemia (due to low energy reserves) and can also be seen in Neonatal Abstinence Syndrome due to withdrawal effects.
  3. Poor Feeding: Hypoglycemia may cause poor feeding due to the lack of energy, and Neonatal Abstinence Syndrome can cause feeding difficulties because of withdrawal symptoms.
  4. Jaundice: Jaundice is a hallmark sign of Neonatal Jaundice, typically due to elevated bilirubin levels.
  5. Loose Stool: Loose stool can be a sign of Neonatal Abstinence Syndrome, as gastrointestinal disturbances are common in withdrawal. It is not typically associated with hypoglycemia or neonatal jaundice.

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