Which assessment finding in a newborn places them at risk for physiological jaundice?

Acrocyanosis.

Mongolian spots.

Cephalohematoma.

Caput succedaneum.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Acrocyanosis, or bluish discoloration of extremities, is a normal newborn finding reflecting immature circulation and does not pose a risk for jaundice. It resolves as circulatory function matures and is unrelated to bilirubin metabolism or hemolysis.

Choice B rationale

Mongolian spots are benign pigmented birthmarks caused by trapped melanocytes in the dermis. These spots have no connection to jaundice and do not reflect bilirubin accumulation or red blood cell breakdown.

Choice C rationale

Cephalohematoma results from birth trauma, causing localized blood collection between the skull and periosteum. The breakdown of pooled blood increases bilirubin production, raising jaundice risk. This complication reflects excessive hemolysis, leading to bilirubin elevation.

Choice D rationale

Caput succedaneum involves superficial scalp swelling due to delivery pressure. Unlike cephalohematoma, it does not contribute to hemolysis or bilirubin accumulation. It resolves spontaneously and poses no risk for jaundice development.

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Correct Answer is A

Explanation

Choice A rationale

Blue-gray discolorations on the sacrum, commonly known as Mongolian spots, are benign skin markings that frequently appear in newborns of Asian, African, and Hispanic descent. Documenting this finding ensures accurate medical records and prevents misinterpretation of these congenital marks as bruising.

Choice B rationale

There is no need to notify the healthcare provider about Mongolian spots unless there is uncertainty regarding their origin. These spots are non-pathological and typically fade within the first years of life, requiring no medical intervention or immediate attention.

Choice C rationale

Clotting studies are unnecessary for blue-gray discoloration because Mongolian spots are not related to blood clotting disorders. They are caused by the accumulation of melanocytes in the dermis during fetal development, a harmless pigmentation phenomenon.

Choice D rationale

Reporting parents to Child Protective Services in this context would be inappropriate and unjustified. Mongolian spots are a common and well-documented congenital skin feature, not indicative of abuse, and misinterpreting them could lead to undue stress and harm to the family. .

Correct Answer is ["75"]

Explanation

Step 1 is (50 mg × 6 kg) ÷ 24 hours. The total daily dose calculates to 300 mg/day.

Step 2 is 300 mg ÷ 4 doses/day. Each dose calculates to 75 mg of Amoxicillin.

Final calculated dose per administration is 75 mg.

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Which assessment finding in a newborn places them at risk for physiological jaundice?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When performing an initial assessment on a full-term infant whose parents are Asian, the nurse notes a blue-gray discoloration across the sacrum of the newborn.What is the most appropriate action for the nurse to take?

Correct Answer is A

Explanation

As the nurse caring for an infant who has been prescribed Amoxicillin (Amoxil) orally every 6 hours, you need to calculate the dose. The recommended dosage is 50 mg/kg/day, divided into multiple doses. If the infant weighs 6 kg, how much Amoxicillin should you administer per dose?

Correct Answer is ["75"]

Explanation

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