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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Related Questions
Correct Answer is D
Explanation
Choice A rationale
If both the client and the newborn are Rh positive, there is no risk of Rh incompatibility, and Rho(D) immune globulin is not needed.
Choice B rationale
If the client is Rh positive and the newborn is Rh negative, there is no risk of Rh incompatibility, and Rho(D) immune globulin is not needed.
Choice C rationale
If both the client and the newborn are Rh negative, there is no risk of Rh incompatibility, and Rho(D) immune globulin is not needed.
Choice D rationale
If the client is Rh negative and the newborn is Rh positive, there is a risk of Rh incompatibility, and Rho(D) immune globulin is needed to prevent the development of Rh sensitization in future pregnancies. .
Correct Answer is B
Explanation
Choice A rationale
Gestational hypertension is diagnosed when high blood pressure develops after 20 weeks of pregnancy without other symptoms of preeclampsia, such as proteinuria or end-organ dysfunction.
Choice B rationale
Preeclampsia with severe features includes high blood pressure, proteinuria, and symptoms like blurred vision and headaches. These indicate severe disease, which can endanger both the mother and the fetus if left untreated.
Choice C rationale
Preeclampsia without severe features involves high blood pressure and proteinuria but without the additional severe symptoms like blurred vision and headache.
Choice D rationale
Chronic hypertension refers to high blood pressure that was present before pregnancy or diagnosed before 20 weeks of gestation. It does not typically present with acute symptoms like blurred vision and headache that develop suddenly.
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