A nurse is collecting data on a 1-day-old newborn.
Which of the following findings should the nurse identify as requiring follow-up?
A hymenal tag and white discharge on genitalia.
Edema on the scalp that crosses the suture line.
A heart murmur.
A large, deep sacral dimple above the gluteal cleft.
The Correct Answer is D
Choice A rationale
A hymenal tag and white discharge on the genitalia are normal findings in newborn females, often due to maternal hormone exposure.
Choice B rationale
Edema on the scalp that crosses suture lines, known as caput succedaneum, is common and typically resolves on its own without intervention.
Choice C rationale
A heart murmur in a newborn can be normal, as many murmurs are benign and resolve as the newborn's circulation adjusts post-birth.
Choice D rationale
A large, deep sacral dimple above the gluteal cleft can be an indication of underlying spinal abnormalities, such as spina bifida, and requires further evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Initiating the Hypoglycemia Protocol is necessary when the blood sugar is <70 mg/dL to quickly raise blood glucose levels.
Choice B rationale
No insulin is administered when blood sugar levels are between 70-130 mg/dL as it is within the normal range.
Choice C rationale
Administering 2 units of insulin for blood sugar levels between 131-180 mg/dL helps lower glucose to the normal range.
Choice D rationale
Administering 4 units of insulin for blood sugar levels between 181-240 mg/dL is necessary to reduce hyperglycemia.
Choice E rationale
Administering 6 units of insulin for blood sugar levels between 241-300 mg/dL addresses more severe hyperglycemia.
Choice F rationale
Administering 8 units of insulin for blood sugar levels between 301-350 mg/dL is used to manage significant hyperglycemia.
Choice G rationale
Administering 10 units of insulin for blood sugar levels between 351-400 mg/dL is crucial for severe hyperglycemia.
Choice H rationale
Administering 12 units of insulin and calling the physician for blood sugar levels >400 mg/dL is critical for immediate medical intervention.
Correct Answer is D
Explanation
Choice A rationale
In pregestational type 1 diabetes mellitus, insulin needs typically decrease during the first trimester due to increased insulin sensitivity and decreased food intake from nausea and vomiting, not an increased dosage.
Choice B rationale
Hypotension is not a typical finding associated with pregestational type 1 diabetes mellitus. Instead, hyperglycemia and its complications, such as ketoacidosis, are more relevant concerns.
Choice C rationale
While weight gain is monitored in diabetic pregnancies, excessive weight gain is not a specific condition associated with pregestational type 1 diabetes mellitus. Weight management should be appropriate to avoid complications.
Choice D rationale
Polyphagia, or increased hunger, is a symptom associated with diabetes mellitus due to the body's inability to properly utilize glucose, leading to increased appetite and higher blood glucose levels.
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