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A nurse is assessing a 1-hour-old newborn.
Which of the following findings should the nurse report to the provider?

A.

Transient circumoral cyanosis.

B.

Transient strabismus.

C.

Caput succedaneum.

D.

Generalized petechiae.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Transient circumoral cyanosis is common in newborns, especially when crying or feeding, and usually resolves on its own without intervention.

 

Choice B rationale

Transient strabismus, or the temporary crossing of the eyes, is normal in newborns due to underdeveloped eye muscles and usually resolves as the infant grows.

 

Choice C rationale

Caput succedaneum is the swelling of the scalp caused by pressure during delivery. It is usually benign and resolves within a few days without treatment.

 

Choice D rationale

Generalized petechiae, or small red or purple spots on the skin, can indicate a serious underlying condition such as a clotting disorder or infection and requires immediate medical evaluation.


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View Related questions

Correct Answer is B

Explanation

Choice A rationale

Elevated BUN levels (25 mg/dL) can indicate kidney dysfunction, dehydration, or high protein intake. However, it’s not directly related to a prenatal complication, though it still

requires monitoring.

Choice B rationale

Hemoglobin (Hgb) of 10.2 mg/dL is below the normal range (11 to 16 mg/dL) and can indicate anemia. During pregnancy, anemia can lead to serious complications such as preterm

birth and low birth weight, making this result significant.

Choice C rationale

A fasting blood glucose level of 70 mg/dL falls within the normal range (70 to 110 mg/dL) and does not indicate a complication. Thus, it is not concerning in the context of prenatal

complications.

Choice D rationale

Hematocrit (Hct) of 32% is slightly below the normal range (33 to 47%), which can be common in pregnancy due to increased plasma volume. While monitoring is required, it’s not as

critical as anemia.

Correct Answer is D

Explanation

Choice A rationale

Uterine contractions occur more frequently than every 15 minutes during the active phase of labor, typically every 2-3 minutes.

Choice B rationale

A fetal heart rate baseline of 166/min is considered tachycardia and may not be normal during labor.

Choice C rationale

Late decelerations are concerning and not expected as they may indicate fetal distress.

Choice D rationale

Contractions lasting about 75 seconds are expected during the active phase of labor.

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