Four newborns are in the nursery. The nurse would report which assessment finding to the healthcare provider?
A 16-hour-old newborn who has not passed any meconium.
A 16-hour-old newborn whose glucose level is 55 mg/dL.
A 2-day-old newborn who is breathing irregularly at 70 breaths/minute.
A 2-day-old newborn who is excreting a milky discharge from both nipples.
The Correct Answer is C
Choice A rationale
The normal range for meconium passage is generally within the first 24 to 48 hours of life. A 16-hour-old newborn who has not yet passed any meconium is still within the expected time frame and is not an immediate cause for alarm, although documentation is important. However, the nurse should continue to monitor for bowel sounds and abdominal distention.
Choice B rationale
The normal blood glucose level for a newborn is typically 45 mg/dL or higher. A glucose level of 55 mg/dL for a 16-hour-old newborn is within the acceptable and safe range, indicating adequate metabolic function and requiring only routine monitoring rather than immediate reporting to the healthcare provider.
Choice C rationale
A respiratory rate of 70 breaths/minute in a 2-day-old newborn (48 hours old) is tachypnea, as the normal range is 30 to 60 breaths/minute. Persistent tachypnea beyond the immediate transitional period, especially when associated with an irregular pattern, is a sign of potential respiratory distress or other underlying pulmonary or cardiac pathology and must be reported immediately.
Choice D rationale
Excreting a milky discharge (sometimes called "witch's milk") from the nipples in both female and male newborns is a common and benign temporary condition caused by the withdrawal of maternal hormones (estrogen and prolactin) after birth. This is a normal, transient finding and does not require reporting to the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Circumcision is a surgical procedure that removes the foreskin of the penis. While it is associated with a lower risk of acquiring some sexually transmitted infections like HIV, it does not prevent all of them, making condom use and safe sexual practices the primary preventive measures. Furthermore, this statement is not a balanced, educational response for undecided parents, who require comprehensive information on risks and benefits.
Choice B rationale
Maintaining adequate hygiene is possible in both circumcised and uncircumcised males. For uncircumcised males, proper hygiene involves gently retracting the foreskin daily after infancy to cleanse the glans, preventing the accumulation of smegma. This statement presents an exaggerated and often incorrect difficulty, failing to provide factual, unbiased information to the parents.
Choice C rationale
While the procedure is associated with pain, standard practice involves administering appropriate pain management, such as a dorsal penile nerve block or topical anesthetic, along with non-pharmacologic measures like sucrose solution and non-nutritive sucking. Therefore, the pain is controllable, and this statement is insufficient to guide a final parental decision.
Choice D rationale
The nurse's role is to provide objective information and support the parents' decision-making process, not to give a personal recommendation or push a specific viewpoint. Recommending a discussion with the healthcare provider ensures the parents receive a detailed, evidence-based review of both the potential medical benefits and risks associated with the procedure.
Correct Answer is A
Explanation
Choice A rationale
Skeletal traction involves inserting a pin directly into the bone to apply a continuous pulling force, typically used for complex fractures or severe orthopedic deformities. This is generally not a primary or common treatment for cerebral palsy, where management focuses on function, muscle tone, movement, and joint stability using non-invasive or less invasive techniques.
Choice B rationale
Physical therapy is a fundamental and expected treatment for cerebral palsy (CP). It focuses on improving muscle strength, mobility, balance, gait, and coordination. Specific exercises and techniques are employed to maximize functional independence and minimize the progression of secondary musculoskeletal complications.
Choice C rationale
Orthotics, such as ankle-foot orthoses (AFOs) or braces, are commonly prescribed treatments in the plan of care for children with CP. They provide support, maintain proper body alignment, prevent or correct deformities, and enhance walking ability by assisting with muscle control and joint stability during movement.
Choice D rationale
Occupational therapy is an essential component of the CP treatment plan. It addresses fine motor skills, activities of daily living (ADLs) like dressing and feeding, and visual-motor integration. The goal is to maximize the child's independence in self-care, school, and play activities tailored to their specific deficits.
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