A nurse is preforming a newborn assessment. Which assessment finding will cause the nurse to intervene immediately?
Lack of reflexes
Cyanotic hands and feet
Had Molding
A soft, protuberant abdomen
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A,B,C,D,E
Explanation
Erikson's psychosocial stages are arranged in a developmental order from birth to adolescence, with each stage focusing on a specific conflict or challenge in a child’s growth.
Trust vs. mistrust occurs from birth to around 18 months, where infants learn to trust or mistrust based on their caregivers' consistency.
Autonomy vs. shame and doubt happens from 18 months to 3 years, where toddlers develop a sense of personal control.
Initiative vs. guilt takes place from 3 to 5 years, where preschoolers initiate activities and interactions or experience guilt when their actions don’t meet expectations.
Industry vs. inferiority occurs from 6 to 12 years, as children develop competence and learn new skills.
Identity vs. role confusion happens during adolescence (12-18 years) when teens explore their identity and sense of self.
Correct Answer is D
Explanation
A. While patient advocacy is important, this is not the central message of the Speak Up Initiatives.
B. Although mistakes can happen, the primary focus of the Speak Up Initiatives is on encouraging patients to be active in their care.
C. The nurse is an important part of the healthcare team, but the focus of the initiative is on empowering patients, not elevating one professional role above others.
D. The Speak Up Initiatives encourage patients to ask questions and seek clarification to ensure understanding and participation in their care.
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