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A nurse in the newborn nursery is caring for a group of newborns. Which of the following newborns requires immediate intervention?

A.

A newborn who is 12 hours post-delivery and has a temperature of 37.0°C (98.6°F).

B.

A newborn who is 27 hours post-delivery and has not voided.

C.

A newborn who is 18 hours post-delivery and has not passed meconium.

D.

A newborn who is 18 hours post-delivery and has acrocyanosis.

Answer and Explanation

The Correct Answer is B

Choice A rationale

 

A newborn with a temperature of 37.0°C (98.6°F) is within the normal range for newborns and does not require immediate intervention.

 

Choice B rationale

 

A newborn who has not voided within 27 hours post-delivery requires immediate intervention. Newborns should void within the first 24 hours of life. Failure to void may indicate dehydration, urinary tract obstruction, or renal issues.

 

Choice C rationale

 

A newborn who has not passed meconium within 18 hours post-delivery is concerning but not as urgent as not voiding. Newborns typically pass meconium within the first 24-48 hours.

 

Choice D rationale

 

Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns and usually resolves on its own. It does not require immediate intervention.

 


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View Related questions

Correct Answer is A

Explanation

Choice A rationale

The Babinski reflex is elicited by stroking the outer edge of the sole of the newborn’s foot, moving up toward the toes. This causes the big toe to move upward and the other toes to fan out.

Choice B rationale

Turning the newborn’s head quickly to one side is used to elicit the tonic neck reflex, not the Babinski reflex.

Choice C rationale

Holding the newborn vertically and allowing one foot to touch the table surface is used to elicit the stepping reflex, not the Babinski reflex.

Choice D rationale

Clapping near the crib and making a loud noise is used to elicit the startle (Moro) reflex, not the Babinski reflex.

Correct Answer is C

Explanation

Choice A rationale

Faint red marks on the plantar surface are more common in preterm infants and are not typically seen in post-term infants.

Choice B rationale

Copious vernix is usually seen in preterm infants. Post-term infants often have little to no vernix.

Choice C rationale

Dry, cracked skin is a common finding in post-term infants due to prolonged exposure to the amniotic fluid.

Choice D rationale

Scant scalp hair is more common in preterm infants. Post-term infants usually have more developed hair.

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