A nurse is caring for a newborn immediately following birth.

Exhibits

The nurse is assessing the newborn 24 hr later.

How should the nurse interpret the findings?

For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication that the client's condition is improving, or an indication that the client's condition is worsening.

Findings 24 hr later:

Color: Consistent with genetic background.

Axillary temperature 36.3° C (97.4°F). Reflex irritability: cry.

Muscle tone: flaccid.

Respiration effort: good cry.

Heart rate 140/min.

Answer and Explanation

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

Color: Consistent with genetic background
- Interpretation: B) Sign of potential improvement
- Rationale: The newborn’s color being consistent with their genetic background indicates a normal adjustment and is not a sign of deterioration. This suggests improvement from the initial condition of acrocyanosis.
Axillary Temperature: 36.3°C (97.4°F)
- Interpretation: B) Sign of potential improvement
- Rationale: The axillary temperature is within the normal range (36.1°C to 37.2°C), which is a positive sign and suggests that the newborn is maintaining normal body temperature.
Reflex Irritability: Cry
- Interpretation: B) Sign of potential improvement
- Rationale: A good cry indicates normal reflex irritability and is a positive sign of neurological and overall well-being.
Muscle Tone: Flaccid
- Interpretation: C) Sign of potential worsening condition
- Rationale: Flaccid muscle tone is concerning as it might indicate a worsening condition or potential neurological issues. It is less typical for muscle tone to be flaccid after the initial adjustment period.
Respiration Effort: Good cry
- Interpretation: B) Sign of potential improvement
- Rationale: A good cry indicates effective respiration and is a positive sign of the newborn’s respiratory status.
Heart Rate: 140/min
- Interpretation: B) Sign of potential improvement
- Rationale: The heart rate is within the normal range for newborns (120-160/min), indicating that the cardiovascular system is functioning properly.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Choice A rationale:
Replacing the infant’s identification band after his name has been recorded is not a recommended practice for newborn identification.
Choice B rationale:
Checking the newborn’s identification using the crib card is not a recommended practice for newborn identification.
Choice C rationale:
Obtaining an imprint of the infant’s feet prior to taking him to the nursery is a reliable method of identification of the newborn.
Choice D rationale:
Requiring visitors to wear an identification band is not a recommended practice for newborn identification.

A. Single palmar creases. B. Rust-stained urine. C. Transient circumoral cyanosis. D. Subconjunctival hemorrhage.

Correct Answer is A

Explanation

The correct answer is choice A. Single palmar creases.

Choice A rationale: Single palmar creases (also known as simian creases) can be associated with certain genetic conditions, such as Down syndrome. The presence of this finding in a newborn should prompt further investigation and reporting to the healthcare provider for additional assessment and possible genetic testing.

Choice B rationale: Rust-stained urine in a newborn is typically caused by uric acid crystals, which are common and not considered abnormal during the first few days of life. This condition usually resolves without intervention, and it does not require reporting to the provider unless it persists or is accompanied by other symptoms.

Choice C rationale: Transient circumoral cyanosis is a common finding in newborns, especially when crying or feeding. It usually resolves on its own and is not considered an alarming sign unless it persists or is associated with central cyanosis or other signs of respiratory distress.

Choice D rationale: Subconjunctival hemorrhage is a common finding in newborns, usually resulting from the pressure changes during delivery. It typically resolves on its own within a few weeks and does not require reporting to the provider unless there are signs of other underlying conditions.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse manager is revising a maternal unit policy to ensure proper identification of newborns. Which of the following should the nurse include in the policy?

Correct Answer is C

Explanation

A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?

Correct Answer is A

Explanation

A nurse in a clinic is caring for an adolescent client who requests a prescription for birth control. Which of the following questions should the nurse ask?

A nurse is assessing a newborn who is 2 hr old. Which of the following findings is an indication of hypoglycemia? (Select all that apply.).

A nurse is assessing the results of a nonstress test for an antepartal client at 35 weeks of gestation. Which of the following findings should indicate to the nurse the need for further diagnostic testing?

A nurse is caring for a client who is experiencing an amniotic fluid embolism during labor. Which of the following actions should the nurse take?

A nurse is caring for a client who is postpartum and just delivered a newborn who weighs 4.5 kg (10 lb). Which of the following manifestations should the nurse recognize as a potential sign of hemorrhage?

A nurse is caring for a postpartum client who recently had an indwelling urinary catheter removed. Which of the following findings indicates that the client is able to void effectively?

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