The nurse caring for a newborn in the maternal-newborn unit notes the objective finding shown in the diagram. What is the appropriate nursing intervention?

Document the findings as a vernix caseosa and is consider it normal.

Report the parents to the department of children and families.

Educate the parents that the findings are normal and should fade away by the age of three.

Notify the healthcare provider.

Answer and Explanation

The Correct Answer is C

A.   Documenting the findings is also important, but it should be noted as Mongolian blue spots rather than vernix caseosa.
B.   Reporting the parents to the department of children and families would be inappropriate, as Mongolian blue spots are not a sign of abuse or neglect
C.   Mongolian blue spots, also known as congenital dermal melanocytosis, are benign skin markings that are usually present at birth or appear shortly after. They are more common in individuals with darker skin tones and are not indicative of any disease or disorder.
D.   While it is always prudent to notify the healthcare provider of any findings, in the case of Mongolian blue spots, no immediate medical intervention is necessary.

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Correct Answer is C

Explanation

A. Metabolic acidosis would present with a low pH and low HCO3-.

B. Metabolic alkalosis would show elevated HCO3- with a normal or elevated PaCO2.

C. The elevated pH and decreased PaCO2 indicate respiratory alkalosis, likely due to hyperventilation.

D. Respiratory acidosis would involve a low pH and high PaCO2.

A. "I take electrolyte supplements because I am on a diuretic". B. "My blood glucose has been very high lately because I have type I diabetes. C. I have been vomiting everything I ate and drank for the past 2 days". D. "At home we eat a lot of green leafy vegetables". E. "I've had diarrhea for several days".

Correct Answer is ["B","C","E"]

Explanation

A. Taking electrolyte supplements would likely prevent hypokalemia unless the intake is insufficient.

B. High blood glucose levels can lead to osmotic diuresis, causing loss of potassium through urine.

C. Vomiting results in loss of potassium and other electrolytes, leading to hypokalemia.

D. Green leafy vegetables are rich in potassium and would help maintain potassium levels rather than deplete them.

E. Diarrhea leads to excessive potassium loss, contributing to hypokalemia.

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The nurse caring for a newborn in the maternal-newborn unit notes the objective finding shown in the diagram. What is the appropriate nursing intervention?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is obtaining a health history from a client that has a serum potassium level of 3.2 mEq (3.5-5.0 mEq). What statements made by the client indicate a potential cause of this clinical manifestation? Select All That Apply.

Correct Answer is ["B","C","E"]

Explanation

During a physical examination of a client's breast, which finding would the nurse recognize as a possible indication of a malignant tumor?

The nurse is collecting a medical history on a 34-year old client. The client reports: "I take oral antibiotics whenever she gets a sore throat, because she cannot afford to lose any time at work". What is the nurse's best response?

The nurse caring for a newborn in the maternal-newborn unit notes the objective finding shown in the diagram. What is the appropriate nursing intervention?

Upon auscultating a client's lungs, the nurse notes there is a low-pitched, continuous respiratory sound that has a snoring quality. How should the nurse interpret and document the findings?

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