While changing a female newborn's diaper, the nurse observes a mucus-like, slightly bloody vaginal discharge.
Which action would the nurse do next?
Document as a normal finding.
Notify the primary care provider immediately.
Obtain a culture of the discharge.
Inspect for engorgement.
The Correct Answer is A
Choice A rationale
The presence of a mucus-like, slightly bloody vaginal discharge, sometimes called pseudomenstruation, in a female newborn is a physiological phenomenon. This discharge is caused by the sudden withdrawal of maternal hormones, specifically estrogens, that crossed the placenta during the third trimester. It is a temporary, benign finding and the appropriate action is to document it as normal.
Choice B rationale
Notifying the primary care provider immediately is unnecessary as this finding is a well-recognized and expected hormonal effect in female newborns due to maternal estrogen withdrawal. Immediate notification would be warranted only if the bleeding was excessive, persistent, foul-smelling, or accompanied by other signs of illness or trauma.
Choice C rationale
Obtaining a culture of the discharge is not routinely indicated because the discharge is known to be physiological and not infectious in origin. A culture would only be necessary if the discharge was purulent, malodorous, or if the newborn showed systemic signs of infection, such as fever or lethargy.
Choice D rationale
While engorgement (swelling) of the breasts in newborns, regardless of sex, is another common finding related to maternal hormone transfer, it is a separate and distinct physical finding from the vaginal discharge. Inspecting for engorgement would not be the direct action needed to manage or assess the observed vaginal bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
The normal range for meconium passage is generally within the first 24 to 48 hours of life. A 16-hour-old newborn who has not yet passed any meconium is still within the expected time frame and is not an immediate cause for alarm, although documentation is important. However, the nurse should continue to monitor for bowel sounds and abdominal distention.
Choice B rationale
The normal blood glucose level for a newborn is typically 45 mg/dL or higher. A glucose level of 55 mg/dL for a 16-hour-old newborn is within the acceptable and safe range, indicating adequate metabolic function and requiring only routine monitoring rather than immediate reporting to the healthcare provider.
Choice C rationale
A respiratory rate of 70 breaths/minute in a 2-day-old newborn (48 hours old) is tachypnea, as the normal range is 30 to 60 breaths/minute. Persistent tachypnea beyond the immediate transitional period, especially when associated with an irregular pattern, is a sign of potential respiratory distress or other underlying pulmonary or cardiac pathology and must be reported immediately.
Choice D rationale
Excreting a milky discharge (sometimes called "witch's milk") from the nipples in both female and male newborns is a common and benign temporary condition caused by the withdrawal of maternal hormones (estrogen and prolactin) after birth. This is a normal, transient finding and does not require reporting to the healthcare provider.
Correct Answer is ["A","B","E"]
Explanation
Choice A rationale
A stiff neck, or nuchal rigidity, is a classic sign of meningeal irritation, which is characteristic of meningitis, especially the bacterial form. The stiffness and pain occur because inflammation of the meninges surrounding the brain and spinal cord causes muscle spasm when the neck is passively flexed, significantly restricting the range of motion.
Choice B rationale
Photophobia, an extreme sensitivity to light, is caused by the irritation and inflammation of the meninges, particularly those surrounding the optic nerve roots. This symptom is a common indicator of increased intracranial pressure and meningeal inflammation associated with bacterial meningitis, signaling a severe central nervous system infection.
Choice C rationale
Headache is one of the most common and prominent symptoms of meningitis, resulting from the combination of meningeal inflammation, increased intracranial pressure, and cerebral edema. Therefore, the absence of a headache would be an atypical finding, making its presence, not absence, a finding that supports the suspicion of bacterial meningitis.
Choice D rationale
A positive Brudzinski sign, which is the involuntary flexion of the hips and knees when the patient's neck is passively flexed, is a classic sign of meningeal irritation. A negative Brudzinski sign indicates the absence of this specific sign of meningeal irritation, suggesting a lower likelihood of meningitis, though its absence does not rule out the disease.
Choice E rationale
Vomiting, often projectile and without preceding nausea, is a common symptom in both children and adolescents with bacterial meningitis. This symptom is typically a direct consequence of the sudden increase in intracranial pressure caused by the inflammation and edema within the central nervous system, irritating the vomiting center in the brainstem.
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