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. Increased subcutaneous fat is a finding that is expected for a newborn who is large for gestational age, not post-term. Post-term newborns tend to have less subcutaneous fat due to the depletion of their glycogen stores.
Choice B reason: This statement is true. Dry, cracked skin is a finding that is expected for a post-term newborn. This is because the amniotic fluid volume decreases as the pregnancy progresses beyond the due date, and the skin loses its moisture and elasticity⁶.
Choice C reason: This statement is false. Copious vernix is a finding that is expected for a preterm newborn, not post-term. Vernix is a white, cheesy substance that covers the skin of the fetus and protects it from the amniotic fluid. It decreases as the fetus matures and is usually absent in post-term newborns.
Choice D reason: This statement is false. Scant scalp hair is a finding that is expected for a preterm newborn, not post-term. Scalp hair grows as the fetus develops and is usually abundant in post-term newborns.
Correct Answer is D
Explanation
Choice A reason: This statement is false. Shoulder presentation is when the fetus is lying transversely in the uterus, with the shoulder as the presenting part. It is not compatible with a vaginal delivery and requires a cesarean section. It is not related to the RSA position, which indicates the fetal orientation in relation to the maternal pelvis.
Choice B reason: This statement is false. Breech presentation is when the fetus is lying in the uterus with the buttocks or feet as the presenting part. It can be complete, incomplete, or frank breech. It is associated with a higher risk of complications and may require a cesarean section. It is not related to the RSA position, which indicates the fetal orientation in relation to the maternal pelvis.
Choice C reason: This statement is false. Mentum presentation is when the fetus is lying in the uterus with the chin as the presenting part. It is a rare type of face presentation, which occurs when the fetal head is hyperextended. It is associated with a higher risk of complications and may require a cesarean section. It is not related to the RSA position, which indicates the fetal orientation in relation to the maternal pelvis.
Choice D reason: This statement is true. Vertex presentation is when the fetus is lying in the uterus with the head as the presenting part. It is the most common and favorable type of presentation for a vaginal delivery. It is related to the RSA position, which indicates that the fetal back is on the right side of the m
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