The nurse is most concerned about which assessment finding?

Pseudomenstration.

Positive Ortolan's test.

Dermal melanosis.

Gynecomastia.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Pseudomenstration is a normal finding in newborn females due to the withdrawal of maternal hormones. It is not a cause for concern and typically resolves within a few days after birth.

Choice B rationale:

Positive Ortolan's test is a concerning finding in a newborn and indicates the possibility of developmental dysplasia of the hip (DDH). This test is used to check for hip instability, and a positive result may warrant further evaluation and intervention to prevent long-term hip problems.

Choice C rationale:

Dermal melanosis, also known as Mongolian spots, is a common benign condition in newborns with dark skin. It appears as blue or gray patches and typically fades within the first few years of life. While it may be alarming to parents, it is not a cause for immediate concern.

Choice D rationale:

Gynecomastia, the enlargement of breast tissue in male infants, is relatively common and is caused by the transfer of maternal hormones during pregnancy. It usually resolves on its own within a few weeks and does not pose a significant health risk.

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Correct Answer is B

Explanation

The nurse should use the lower ribcage border to measure chest circumference.

Choice A rationale:

The sternal notch is not an appropriate landmark for measuring chest circumference. It is a notch at the top of the sternum and not indicative of chest circumference.

Choice B rationale:

When measuring the chest circumference of a newborn, the correct anatomical landmark to use is the nipple line. This method ensures that the measurement is taken at a consistent and reproducible location across different individuals, providing an accurate assessment of the chest size relative to growth and development standards. It's important to position the measuring tape at the level of the nipples, encircling the chest at its largest point, which typically aligns with the nipple line.

Choice C rationale:

The lower ribcage border is also not suitable as it may vary significantly with respiratory movements and is not a stable landmark for consistent measurements.

Choice D rationale:

The axillae (armpits) are not used as a landmark for measuring chest circumference. It is not a standardized anatomical point for this purpose.

A. The newborn with significant bruising from a face presentation. B. The premature newborn. C. The baby born at 41 weeks' gestation. D. The newborn with O+ blood type, born to a mother with O- blood type.

Correct Answer is C

Explanation

Choice A rationale:

(Incorrect) The newborn with significant bruising from a face presentation is at an increased risk of elevated unconjugated bilirubin levels. Bruising can lead to the breakdown of red blood cells, increasing bilirubin production.

Choice B rationale:

(Incorrect) The premature newborn is at a higher risk of elevated unconjugated bilirubin levels. Premature infants often have an underdeveloped liver, which can lead to reduced bilirubin processing and clearance.

Choice C rationale:

(Correct) The baby born at 41 weeks' gestation is at the lowest risk for elevated unconjugated bilirubin levels. By this stage, the baby's liver is more mature, allowing for efficient processing and clearance of bilirubin.

Choice D rationale:

(Incorrect) The newborn with O+ blood type, born to a mother with O- blood type, is at an increased risk of elevated unconjugated bilirubin levels if the baby's blood type is Rh-positive and the mother's is Rh-negative. This situation can lead to Rh incompatibility and hemolytic disease of the newborn, causing higher bilirubin levels.

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The nurse is most concerned about which assessment finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a newborn. Which of the following anatomical landmarks should the nurse use to measure chest circumference?

Correct Answer is B

Explanation

Which newborn is at the lowest risk for elevated unconjugated bilirubin levels?

Correct Answer is C

Explanation

Exhibit 1. How can the nurse assess the successful transition of the respiratory system in the newborn? (Select All that Apply.).

A nurse is caring for a newborn who was delivered by vacuum extraction and has swelling on his head that crosses the suture line. The newborn's mother asks about the swelling on her newborn's head. Which of the following responses should the nurse make?

The nurse notes that a newborn's white blood cell count (WBC) is 15,000. The nurse is aware that:.

A nurse is reviewing the laboratory results of a newborn that is 4 hr old. Which of the following findings should the nurse identify as the priority?

A nurse in the newborn nursery is receiving a report on four newborns. Which of the following newborns should the nurse see first?

The nurse admits a newborn to the admission nursery and prepares to bathe the baby for the first time after assessing which of the following?

A mother asks, "Why does my infant have blue hands?".