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 C
Explanation
Choice A rationale
2 units is insufficient to bring down a blood sugar level of 152 mg/dL adequately. According to the sliding scale, 2 units typically lower blood sugar by 50-60 mg/dL, which might not be enough for this level.
Choice B rationale
3 units might reduce blood sugar by approximately 75-90 mg/dL. However, this reduction may not be adequate to bring the blood sugar level within the target range, depending on individual response to insulin.
Choice C rationale
4 units of insulin are suitable for a blood sugar level of 152 mg/dL. Generally, 1 unit of insulin lowers blood sugar by 30-50 mg/dL. Administering 4 units should ideally lower the blood sugar level to the desired range.
Choice D rationale
5 units of insulin could result in an excessive drop in blood sugar levels. It could reduce the blood sugar level by 150-200 mg/dL, which might risk hypoglycemia, making it an unsuitable choice for a blood sugar level of 152 mg/dL.
Correct Answer is B
Explanation
Choice A rationale
Checking the client's temperature every 4 hours is important to monitor for infection but is not the primary action during the active phase of labor following an amniotomy.
Choice B rationale
Encouraging the client to empty the bladder every 2 hours helps prevent bladder distention, which can impede the descent of the baby and contribute to labor progress.
Choice C rationale
Bearing down with each contraction is advised during the second stage of labor, not the active phase of the first stage.
Choice D rationale
Maintaining the client in the lithotomy position is not necessary throughout labor and can be uncomfortable; mobility and changing positions are encouraged.
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