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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
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.
Correct Answer is A
Explanation
Choice A rationale
Rhythmic respirations indicate the client is using controlled breathing techniques to manage labor pain, which demonstrates effective coping. This method helps maintain oxygen levels and can reduce the perception of pain through focused breathing.
Choice B rationale
Crying during labor may indicate emotional distress or pain, suggesting the client might be struggling to cope effectively with labor. While it is a natural response, it is not typically associated with controlled coping mechanisms.
Choice C rationale
Lack of concentration can indicate that the client is overwhelmed by pain or anxiety, which may hinder her ability to use coping strategies effectively. It suggests she might be struggling to manage her labor experience.
Choice D rationale
Perspiration is a common physiological response to the exertion and stress of labor, but it does not specifically indicate how well the client is coping with labor pain or stress. It is a normal part of the labor process but not a clear sign of effective coping.
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