A nurse is collecting data from a newborn who is 48 hours old. Which of the following findings should the nurse report to the provider?
Erythema toxicum
Jaundiced skin and yellow tinge to the sclera
Mongolian spot
Telangiectatic nevi
The Correct Answer is B
Choice A reason: This statement is false. Erythema toxicum is a benign rash that appears as red blotches with white or yellow papules in the center. It can occur anywhere on the body except the palms and soles. It is not related to the delivery method or the swelling of the head.
Choice B reason: This statement is true. Jaundiced skin and yellow tinge to the sclera are signs of hyperbilirubinemia, which is a high level of bilirubin in the blood. Bilirubin is a waste product that results from the breakdown of red blood cells. It can cause brain damage if left untreated. The nurse should report this finding to the provider and check the newborn's bilirubin level.
Choice C reason: This statement is false. A Mongolian spot is a bluish-gray or brown patch of skin that is present at birth or shortly after. It is more common in newborns of Asian, African, or Hispanic descent. It is not related to the delivery method or the swelling of the head.
Choice D reason: This statement is false. Telangiectatic nevi are also known as stork bites or salmon patches. They are flat, pink, or red marks that appear on the eyelids, nose, forehead, or nape of the neck. They are caused by dilated capillaries and usually fade by the second year of life. They are not related to the delivery method or the swelling of the head.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This statement is false. Four contractions in a 10-minute period is a normal finding for a client who is in labor. It indicates that the labor is progressing and the uterus is contracting effectively.
Choice B reason: This statement is true. Fetal heart rate 100/min for a 10-minute period is an abnormal finding for a client who is in labor. It indicates that the fetus is bradycardic, which means the heart rate is below the normal range of 110 to 160/min. This can be a sign of fetal distress, hypoxia, or cord compression. The nurse should report this finding to the provider and intervene to improve the fetal oxygenation and circulation.
Choice C reason: This statement is false. Contraction lasting 85 seconds is a normal finding for a client who is in labor. It indicates that the contractions are strong and regular, which helps to dilate and efface the cervix.
Choice D reason: This statement is false. Contraction resting period 35 seconds is a normal finding for a client who is in labor. It indicates that the contractions are spaced out enough to allow the uterus and the placenta to relax and replenish the blood supply and oxygen to the fetus.
Correct Answer is D
Explanation
Choice A reason: This statement is incorrect. Hyperactivity is not a common effect of smoking during pregnancy. However, some studies suggest that smoking during pregnancy may increase the risk of attention-deficit/hyperactivity disorder (ADHD) in children.
Choice B reason: This statement is incorrect. Craniofacial abnormalities are not a common effect of smoking during pregnancy. However, some studies suggest that smoking during pregnancy may increase the risk of cleft lip and cleft palate in babies⁶.
Choice C reason: This statement is incorrect. Hypersensitivity to noise is not a common effect of smoking during pregnancy. However, some studies suggest that smoking during pregnancy may affect the development of the auditory system and hearing in children.
Choice D reason: This statement is correct. Low birth weight is a common and serious effect of smoking during pregnancy. Smoking during pregnancy can reduce the amount of oxygen and nutrients that reach the fetus, and cause tissue damage in the fetus, especially in the lungs and brain. Smoking during pregnancy can also increase the risk of preterm delivery, which is a leading cause of death and disability among newborns..
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today