A nurse in the newborn nursery is caring for a group of newborns. Which of the following newborns requires immediate intervention?
A newborn who is 12 hours post-delivery and has a temperature of 37.0°C (98.6°F).
A newborn who is 27 hours post-delivery and has not voided.
A newborn who is 18 hours post-delivery and has not passed meconium.
A newborn who is 18 hours post-delivery and has acrocyanosis.
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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Correct Answer is B
Explanation
Choice A rationale
Erythema toxicum is a common, benign rash in newborns but does not cause swelling that crosses suture lines.
Choice B rationale
A caput succedaneum is swelling of the scalp that crosses suture lines and is caused by prolonged pressure on the head during delivery.
Choice C rationale
Mongolian spots are benign, flat, congenital birthmarks with wavy borders and irregular shapes, typically found on the lower back and buttocks, not the head.
Choice D rationale
A cephalhematoma is a collection of blood between the skull bone and its periosteum that does not cross suture lines. .
Correct Answer is B
Explanation
Choice A rationale
Erythema toxicum is a common, benign rash seen in newborns. It appears as red patches with small white or yellow pustules in the center. It is not characterized by small raised pearly white spots on the nose and chin.
Choice B rationale
Milia spots are small raised pearly white spots that commonly appear on the nose, chin, and cheeks of newborns. They are caused by trapped keratin and are harmless, usually resolving on their own within a few weeks.
Choice C rationale
Mongolian spots are flat, blue-gray patches commonly found on the lower back and buttocks of newborns, especially those with darker skin. They are not raised and do not appear on the nose and chin.
Choice D rationale
Epstein’s pearls are small white or yellow cysts found on the gums or roof of the mouth in newborns. They are not found on the nose and chin. .