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The practical nurse (PN) receives shift report for four newborns in the full-term newborn nursery.

Which infant should the PN assess first?

A.

The ten-hour-old with circumoral cyanosis.

B.

The one-day-old with a positive Babinski's reflex

C.

The two-day old with negative Ortolani's sign

D.

The six-hour-old with a large sacral "stork bite"

Answer and Explanation

The Correct Answer is A

Circumoral cyanosis is a bluish discoloration around the mouth that indicates inadequate oxygenation. It is an abnormal finding in a full-term newborn and requires immediate assessment and intervention by the PN.

The other options are not correct because:

  1. A positive Babinski's reflex is a normal finding in newborns that indicates intact neurological function. It is elicited by stroking the sole of the foot and observing the fanning of the toes.
  2. A negative Ortolani's sign is a normal finding in newborns that indicates no hip dislocation or dysplasia. It is elicited by abducting the hips and feeling for any clicking or clunking sensation.
  3. A large sacral "stork bite" is a common benign birthmark that appears as a reddish patch on the lower back or nape of the neck. It usually fades within the first year of life and does not require any treatment.


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Related Questions

Correct Answer is B

Explanation

This is the best response for the PN to provide because it sets a clear and firm boundary for the adolescent and discourages inappropriate or sexual comments. The PN should also redirect the adolescent's atention to another topic or activity and document the incident.

Correct Answer is A

Explanation

The correct answer is Choice A:

The solution should approximate the client's body temperature (98°F or 36°C). Choice A rationale:

The ideal temperature for administering an oil retention enema is to approximate the client's body temperature. Using a solution at the client's body temperature helps to prevent discomfort and potential injury to the rectal mucosa. The temperature of 98°F (36°C) is considered safe and comfortable for the client.

Choice B rationale:

This option is incorrect because the temperature of the enema solution does matter. Administering an enema that is too cold or too hot can cause discomfort, cramping, and potential damage to the rectal tissue.

Choice C rationale:

This option is not the best choice because relying solely on the client's comfort level may not ensure the optimal temperature for the enema solution. The client's perception of comfort can vary, and it may not necessarily reflect the ideal temperature for administration.

Choice D rationale:

This option is incorrect because using a temperature higher than the client's body temperature, such as 110°F (43°C), can be harmful and increase the risk of burns or injury to the rectal lining.

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