A nurse is completing a newborn assessment and notices small white nodules on the roof of the newborn’s mouth. This finding is characteristic of which of the following conditions?

Erythema toxicum

Mongolian spots

Epstein’s pearls

Milia spots

Answer and Explanation

The Correct Answer is C

Choice A rationale
Erythema toxicum is a common rash seen in newborns, characterized by blotchy red spots on the skin with overlying white or yellow papules or pustules. It does not present as small white nodules on the roof of the mouth.
Choice B rationale
Mongolian spots are a type of birthmark that are flat, blue, or blue-gray. They appear at birth or in the first or second week of life. They look similar to bruises and are most often found on the buttocks or lower back, but are never found on the roof of the mouth.
Choice C rationale
Epstein pearls are small, harmless white or yellow nodules that may appear along your newborn baby’s gums or on the roof of their mouth. They are common and usually go away within three months after birth.
Choice D rationale
Milia spots are tiny white bumps that appear across a baby’s nose, chin or cheeks. Milia are common in newborns but can occur at any age. Unlike Epstein pearls, they do not appear on the roof of the mouth.

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Correct Answer is D

Explanation

Choice D rationale
The client is experiencing the first stage, latent phase of labor. This phase is characterized by contractions that are typically mild and irregular, occurring every 5-30 minutes and lasting about 30-45 seconds. The cervix dilates from 0 to 3 cm and effaces from 0% to 40%. The fetus descends into the pelvis, but is not yet engaged. The client may feel excited and anxious as labor begins.
Choice A rationale
The first stage, active phase of labor is characterized by regular, strong contractions occurring every 3-5 minutes and lasting about 40-70 seconds. The cervix dilates from 4 to 7 cm and effaces from 40% to 100%. The fetus descends and engages in the pelvis. The client may feel increased discomfort and a strong urge to bear down.
Choice B rationale
The first stage, transition phase of labor is characterized by intense contractions occurring every 2-3 minutes and lasting about 45-90 seconds. The cervix dilates from 8 to 10 cm and effaces from 100%. The fetus descends and engages in the pelvis. The client may feel overwhelmed, restless, and irritable.
Choice C rationale
The second stage of labor begins when the cervix is fully dilated and ends with the delivery of the baby. The contractions are strong, occurring every 2-3 minutes and lasting about 45-90 seconds. The client feels a strong urge to push during contractions.

A. Keep the head of the bed at a 30-degree angle. B. Initiate the use of a PCA pump for pain control. C. Reposition the client by log rolling every 4 hours. D. Place the client in protective isolation.

Correct Answer is B

Explanation

Choice A rationale
Keeping the head of the bed at a 30-degree angle is not typically necessary following scoliosis repair with Harrington rod instrumentation. The position of the bed is usually determined by the patient’s comfort and the surgeon’s specific post-operative instructions.
Choice B rationale
Initiating the use of a PCA (Patient-Controlled Analgesia) pump for pain control is a common intervention following scoliosis repair with Harrington rod instrumentation. This allows the patient to self-administer pain medication as needed, providing effective and individualized pain control.
Choice C rationale
Repositioning the client by log rolling every 4 hours is a common practice after spinal surgery to prevent pressure ulcers and maintain alignment of the spine. However, it is not the primary intervention in this case.
Choice D rationale
Placing the client in protective isolation is not typically necessary following scoliosis repair with Harrington rod instrumentation. Isolation is usually reserved for patients who are at high risk of infection or who have an infection that could be transmitted to others.

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A nurse is completing a newborn assessment and notices small white nodules on the roof of the newborn’s mouth. This finding is characteristic of which of the following conditions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

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Correct Answer is B

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A nurse is completing a newborn assessment and notices small white nodules on the roof of the newborn’s mouth. This finding is characteristic of which of the following conditions?