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A nurse is preforming a newborn assessment. Which assessment finding will cause the nurse to intervene immediately?

A.

Lack of reflexes

B.

Cyanotic hands and feet

C.

Had Molding

D.

A soft, protuberant abdomen

Answer and Explanation

The Correct Answer is A

A. Newborn reflexes (Moro, rooting, grasp) are crucial indicators of neurological function. Absence may suggest brain injury or CNS dysfunction and requires urgent evaluation.
B. Acrocyanosis (blue hands/feet) is normal in newborns for the first 24–48 hours due to immature circulation.
C. Molding (misshapen head from birth canal pressure) is normal and resolves within days.
D. A soft, slightly protuberant abdomen is typical in newborns due to weak abdominal muscles.
 


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Related Questions

Correct Answer is C

Explanation

A. While changes in sexuality may occur in older adults, there is no indication that this is a concern for this client at this time.
B. Retirement can cause psychosocial changes, but this client has been retired for 5 years, making it a less immediate concern.
C. The client is at high risk for social isolation due to widowhood, lack of transportation, rural living, and the absence of a driving license. Social isolation is a major psychosocial risk in older adults and can lead to depression, cognitive decline, and physical deterioration.
D. Environmental factors (rural area, lack of transport) contribute to the risk of social isolation but are not the psychosocial issue itself.

Correct Answer is D

Explanation

A. A flexible family structure would indicate that roles and responsibilities can shift easily, but the husband's statement reflects a rigid view of family roles.
B. Resilience refers to the family's ability to adapt and overcome challenges, which does not align with the husband's statement of feeling overwhelmed.
C. A hardy family would be strong and able to withstand stress, which does not reflect the husband's frustration with the situation.
D. A rigid family structure is characterized by inflexible roles and responsibilities, as indicated by the husband's refusal to take on certain tasks.

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