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 B

Explanation

A. Clubbing is a sign of chronic hypoxia, not acute hypoxemia.

B. Cyanosis, a bluish discoloration of the skin and mucous membranes, is an indicator of acute hypoxemia.

C. Palpating for decreased tactile fremitus is related to fluid or air in the lungs, not specifically hypoxemia.

D. Auscultation for adventitious breath sounds can reveal respiratory issues but does not directly confirm hypoxemia.

A. Client with an acute allergic reaction B. Client with lung cancer reports ongoing cough C. Client with dyspnea on exertion D. Client with sinus infection with nasal discharge

Correct Answer is A

Explanation

A. An acute allergic reaction, especially if involving airway compromise, can be life-threatening and requires immediate attention.

B. The client with lung cancer and a cough is concerning but not as urgent as an acute allergic reaction.

C. Dyspnea on exertion needs evaluation but is not as urgent as a possible airway issue.

D. A sinus infection with nasal discharge is typically not an emergency.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

You are examining a client with respiratory distress. Which physical assessment would best determine if the client has acute hypoxemia?

Correct Answer is B

Explanation

The nurse receives four clients in the emergency department from triage at the same time. Which client requires the nurse's immediate attention?

Correct Answer is A

Explanation

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