The nurse is most concerned about which assessment finding?
Pseudomenstration.
Positive Ortolan's test.
Dermal melanosis.
Gynecomastia.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
"This is a caput succedaneum, which is a collection of fluid from the pressure of the vacuum extractor.”.
Choice A rationale:
A Mongolian spot is a benign, flat, bluish-gray pigmented area often found on the sacral or gluteal area of some newborns with darker skin tones. It is not related to the swelling on the newborn's head caused by vacuum extraction.
Choice B rationale:
A caput succedaneum is a localized swelling on the baby's scalp that occurs due to pressure from the vacuum extractor during delivery. It is typically soft and may cross the suture lines. This explanation accurately describes the swelling the baby has on his head.
Choice C rationale:
Erythema toxicum is a common rash that appears as small red bumps with white or yellow centers. It is a benign and self-resolving condition that does not cause swelling on the head or involve the suture lines.
Choice D rationale:
A cephalhematoma is a collection of blood between the skull and the periosteum that does not cross the suture lines. It is caused by trauma during birth and may take weeks to months to resolve. This does not match the description of the swelling caused by vacuum extraction.
Correct Answer is C
Explanation
Choice A rationale:
Applying crushed cabbage leaves to the breasts can be a traditional remedy to help reduce swelling and discomfort associated with engorgement.
Choice B rationale:
Wearing a snug-fitting bra can help provide support to the breasts and reduce discomfort from breast engorgement. It can also help to avoid stimulation of the breasts, which can decrease milk production in a client who is not breastfeeding. This is an appropriate comfort measure for the client.
Choice C rationale:
Stimulating the nipples by squeezing softly can lead to increased milk production and exacerbate breast engorgement. For a client who is not breastfeeding, this action is not recommended and may worsen the engorgement.
Choice D rationale:
Applying ice packs to the breasts can help reduce inflammation and alleviate discomfort from breast engorgement. This is an appropriate comfort measure for the client who is not breastfeeding.
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