A nurse is caring for four newborns.
Which of the following newborns should the nurse assess first?
A newborn who has subconjunctival hemorrhage of the left eye.
A newborn who has rust-stained urine.
A newborn who has nasal flaring.
A newborn who has overlapping suture lines.
The Correct Answer is C
Choice A rationale
Subconjunctival hemorrhage is a common, generally benign finding in newborns, often resulting from increased intraocular pressure during the birthing process, causing rupture of superficial capillaries in the sclera. It presents as a bright red patch under the conjunctiva and usually resolves spontaneously within a few weeks without intervention, thus it does not warrant immediate, priority assessment.
Choice B rationale
Rust-stained urine, or pink-tinged urine, in a newborn is typically due to the presence of uric acid crystals (urates) in the urine, a normal finding related to concentrated urine and the immaturity of the newborn kidney's ability to concentrate urine fully. This is a common, non-pathological observation in the first few days of life, indicating mild dehydration, but it is not an acute, high-priority concern.
Choice C rationale
Nasal flaring is a significant sign of respiratory distress in a newborn, indicating the infant is attempting to increase the diameter of the nasal passages to decrease airway resistance and enhance the intake of oxygen. This compensatory mechanism suggests compromised gas exchange and potential hypoxemia, requiring immediate assessment and intervention to prevent further respiratory compromise.
Choice D rationale
Overlapping suture lines, also known as molding, occurs when the cranial bones shift and overlap during passage through the narrow birth canal. This is a normal, expected finding, especially after a vaginal delivery, and the shape of the head typically returns to normal within a few days to a week, posing no immediate threat to the newborn.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
Choice A rationale: Uterine contractions occurring every 2 to 3 minutes at 30 weeks gestation are abnormal and indicate preterm labor. Normal uterine activity in the third trimester should not demonstrate such frequency or cervical change until term. The presence of cervical dilation (2 cm) and effacement (80%) confirms labor physiology. Preterm labor poses risks of neonatal respiratory distress, intraventricular hemorrhage, and sepsis. Therefore, this finding requires immediate follow-up to prevent complications associated with premature birth.
Choice B rationale: Abdominal assessment revealed a soft, nontender abdomen with no rebound tenderness. These findings are within normal limits and do not suggest acute abdominal pathology such as placental abruption, appendicitis, or peritonitis. In obstetrics, concerning abdominal findings would include rigidity, tenderness, or guarding. The absence of these signs indicates no emergent intra-abdominal complication. Thus, this assessment does not require follow-up, as it reflects a physiologically normal abdominal exam for a pregnant client.
Choice C rationale: Fundal height at 30 weeks gestation is expected to measure approximately 28 to 32 cm, correlating with gestational age ±2 cm. This client’s fundal height of 28 cm falls within the normal range. Deviations greater than 3 cm could indicate intrauterine growth restriction, oligohydramnios, or macrosomia. Since the measurement is consistent with gestational norms, it does not require follow-up. This finding is physiologically appropriate and does not suggest pathology or abnormal fetal growth at this stage of pregnancy.
Choice D rationale: Abdominal cramping in the third trimester, when associated with cervical dilation and effacement, is a hallmark of preterm labor. Unlike benign Braxton Hicks contractions, which are irregular and non-progressive, these cramps are accompanied by cervical change and regular contractions. This indicates true labor physiology before 37 weeks. Preterm labor increases risks of neonatal morbidity and mortality. Therefore, abdominal cramping in this context requires follow-up to initiate interventions such as tocolysis, corticosteroids, and infection evaluation.
Choice E rationale: Low back pain in pregnancy can be benign due to musculoskeletal strain, but in this case, it is associated with uterine contractions, cervical change, and rupture of membranes. Low back pain is a common presenting symptom of preterm labor due to referred pain from uterine activity. Additionally, fever (38.3°C) and elevated WBC count (22,000/mm³; normal 5,000–10,000/mm³) raise concern for intra-amniotic infection. Thus, low back pain here is pathologic and requires follow-up to rule out chorioamnionitis and manage preterm labor.
Correct Answer is ["A","B"]
Explanation
Choice A rationale: The cervix being closed and thick at 42 weeks gestation is unfavorable and increases the risk for labor complications. At this stage, the cervix should ideally be effaced and dilated to allow for labor progression. A closed, thick cervix indicates poor readiness for labor, which may necessitate induction with cervical ripening agents. Failure of the cervix to ripen increases the risk of prolonged labor, failed induction, and cesarean delivery, making this a significant complication risk factor.
Choice B rationale: Being at 42 weeks gestation is post-term, which increases the risk for labor complications. Post-term pregnancy is associated with oligohydramnios, macrosomia, meconium aspiration, and placental insufficiency. These conditions can lead to fetal distress, shoulder dystocia, and increased rates of operative delivery. Therefore, advanced gestational age beyond 41 weeks is a recognized risk factor for complications, requiring close monitoring and often induction of labor to reduce maternal and neonatal morbidity.
Choice C rationale: A fetal heart rate of 150/min is within the normal baseline range of 110 to 160 beats per minute. This indicates adequate fetal oxygenation and no evidence of tachycardia or bradycardia. Since the FHR is normal and reassuring, it does not increase the risk for labor complications. Continuous monitoring is still important, but this specific finding is not a complication risk factor.
Choice D rationale: Clear to white mucus-like vaginal discharge is a normal physiologic finding in pregnancy, known as leukorrhea. It results from increased estrogen and cervical gland activity. This type of discharge is not associated with infection, rupture of membranes, or preterm labor. Since it is expected and benign, it does not increase the risk for labor complications. Only abnormal discharges such as foul-smelling, green, or bloody secretions would be concerning.
Choice E rationale: Vertex presentation, specifically left occiput anterior, is the most favorable fetal position for vaginal delivery. It allows for optimal alignment of the fetal head with the maternal pelvis, facilitating descent and rotation during labor. Malpresentations such as breech or transverse would increase the risk for complications, but vertex LOA is ideal. Therefore, this finding is favorable and does not increase the risk for labor complications.
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