The following newborns are three-hours old and are sleeping.
The registered nurse should notify the provider about which newborn?

The newborn with a red raised capillary hemangioma on the left forearm.

The newborn with a heart rate of 154 beats/minute.

The newborn with a respiratory rate of 72 breaths/minute.

The newborn with whitish, hardened nodules on the gums of the mouth.

Answer and Explanation

Correct Answer : A,B,C,D

Choice A rationale

Difficulty feeding in infants can result from fatigue caused by inadequate oxygen delivery to tissues due to heart failure. Feeding is a demanding activity that requires energy and coordination, making it an early symptom of cardiac compromise in pediatric patients.

Choice B rationale

Wheezes or rales are caused by pulmonary congestion or edema, which occur in heart failure due to increased pulmonary venous pressure. This congestion results in fluid accumulation in the alveoli, leading to abnormal breath sounds. These findings require prompt evaluation.

Choice C rationale

Edema in the feet and legs results from systemic venous congestion caused by right-sided heart failure. Increased hydrostatic pressure in peripheral veins leads to fluid leakage into interstitial spaces, causing swelling, especially in dependent areas.

Choice D rationale

Tachypnea occurs as a compensatory mechanism in heart failure. Poor cardiac output reduces oxygen delivery, triggering the respiratory center to increase the breathing rate to improve oxygen uptake and delivery. It is an early sign of cardiopulmonary compromise in children.

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Correct Answer is C

Explanation

Choice A rationale

Alcohol swabs are not recommended for cleaning the circumcision site as they may irritate the delicate tissue and delay healing. Proper care involves gentle cleansing with water and avoiding substances that can cause discomfort or tissue damage.

Choice B rationale

While monitoring for bleeding is essential, small spots of blood on the diaper may be normal. Excessive bleeding, however, is a cause for concern and should prompt immediate medical consultation, emphasizing the need to differentiate normal healing signs from complications.

Choice C rationale

A loose diaper reduces pressure on the circumcision site and prevents friction, which could cause pain or disrupt the healing process. This practice ensures the Plastibell stays in position until it detaches naturally, minimizing discomfort and promoting tissue recovery.

Choice D rationale

The Plastibell typically falls off within 5 to 8 days, not within 24 hours. Misunderstanding this timeframe can cause undue anxiety for parents or lead to premature removal attempts, which may complicate the healing process or cause injury to the site.

A. Perform a sharp hand clap near the infant. B. Place a finger at the base of the newborn's toes. C. Hold the newborn vertically allowing one foot to touch the table surface. D. Turn the newborn's head quickly to one side.

Correct Answer is A

Explanation

Choice A rationale

Performing a sharp hand clap near the infant activates the Moro reflex, a startle response present at birth that integrates by around six months of age. The reflex involves symmetric extension and abduction of the arms followed by flexion, demonstrating proper neurological function.

Choice B rationale

Placing a finger at the base of the newborn's toes elicits the plantar grasp reflex, not the Moro reflex. This reflex involves flexion of the toes when pressure is applied to the sole and is unrelated to startling the infant.

Choice C rationale

Holding the newborn vertically allowing one foot to touch the table surface elicits the stepping reflex, not the Moro reflex. This reflex involves simulated walking movements and is unrelated to assessing startle responses.

Choice D rationale

Turning the newborn's head quickly to one side elicits the tonic neck reflex (fencing reflex) rather than the Moro reflex. This reflex involves extension of the limbs on the side the head is turned and flexion on the opposite side. .

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The following newborns are three-hours old and are sleeping.The registered nurse should notify the provider about which newborn?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with a Plastibell technique.Which of the following client statements indicates an understanding of circumcision care?

Correct Answer is C

Explanation

A nurse is caring for a newborn and assessing newborn reflexes.To elicit the Moro reflex, the nurse should take which of the following actions?

Correct Answer is A

Explanation

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Identify a complication resulting from a cleft palate, the anatomical changes that lead to the complication, and the priority interventions for care.

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The following newborns are three-hours old and are sleeping.
The registered nurse should notify the provider about which newborn?