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
The client will be positioned in a prone position is incorrect because the prone position is not used for fetal anatomy ultrasounds.
Choice B rationale
The ultrasound will occur at 13 weeks of gestation is incorrect as the typical timing for a detailed fetal anatomy scan is around 18-22 weeks of gestation, not 13 weeks.
Choice C rationale
The ultrasound will be transvaginal is incorrect because at 20 weeks of gestation, a transabdominal ultrasound is more commonly used rather than a transvaginal one.
Choice D rationale
The client must have a full bladder is correct because a full bladder helps lift the uterus out of the pelvis, providing a clearer view during the ultrasound.
Correct Answer is A
Explanation
Choice A rationale
Checking the fetal heart rate pattern is the priority after an amniotomy. This procedure involves breaking the amniotic sac, which can lead to changes in the fetal heart rate. Immediate assessment ensures the fetus is not in distress.
Choice B rationale
Evaluating for signs of infection is essential post-procedure, but not the immediate priority. Infection signs develop over time, while fetal distress can occur immediately.
Choice C rationale
Observing the color and consistency of amniotic fluid is important for identifying meconium-stained fluid, but it is not as immediately crucial as ensuring fetal well-being.
Choice D rationale
Taking the client's temperature can help monitor for infection later, but it is not the immediate concern following amniotomy. The primary concern is the fetal response.
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