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 D
Explanation
Choice A rationale
An occult cord prolapse occurs when the umbilical cord is hidden but not necessarily within the vagina. It is often compressed alongside the fetus, causing a risk for decreased oxygenation.
Choice B rationale
An occult prolapsed cord is not characterized by being wrapped around the fetal neck; that condition is known as a nuchal cord.
Choice C rationale
A compound prolapsed cord does not involve the cord being felt through the cervix inside an intact amniotic sac. Instead, it involves the cord alongside the fetal presenting part.
Choice D rationale
An overt prolapsed cord occurs when the umbilical cord comes through the cervix ahead of the presenting part, posing significant risk due to potential cord compression and interruption of blood flow to the fetus.
Correct Answer is B
Explanation
Choice A rationale
Cervical dilation is a source of visceral pain during labor due to the stretching and opening of the cervix, and it is not incorrect information.
Choice B rationale
Stretching of the pelvic muscles is incorrect because visceral pain during labor is typically associated with internal organs and not the stretching of pelvic muscles, which is more somatic pain.
Choice C rationale
Nerve stimulation is a cause of visceral pain as labor pain is transmitted through the nerves to the spinal cord and brain.
Choice D rationale
Uterine contractions are a major source of visceral pain during labor as they involve the powerful and rhythmic tightening and relaxing of the uterine muscles.
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