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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 D

Explanation

Choice A rationale

Wound infection usually presents with redness, warmth, and swelling, not just yellow exudate. The presence of yellow exudate alone typically does not indicate an infection.

Choice B rationale

Ulceration would involve the breakdown of skin or tissue, which is not indicated by the presence of yellow exudate. Ulcerations are more severe and painful than normal post-

circumcision healing.

Choice C rationale

Exposure to urine can cause irritation but does not typically result in yellow exudate. Proper diapering and cleaning prevent this irritation, and exudate is part of the healing process,

not a result of urine exposure.

Choice D rationale

Healing is indicated by the presence of yellow exudate, which is a normal part of the healing process post-circumcision. It signifies that the glans is recovering as expected. .

Correct Answer is D

Explanation

Choice A rationale

Elevating the head of the client’s bed is not indicated in this situation and does not address the issue of excessive bleeding postpartum.

Choice B rationale

Administering terbutaline, a medication used to manage preterm labor, is not relevant in the context of postpartum hemorrhage and excessive bleeding.

Choice C rationale

Initiating oxygen at 2 L/min via nasal cannula may help with oxygenation but does not address the primary issue of excessive postpartum bleeding.

Choice D rationale

Initiating an infusion of oxytocin is the correct action as it helps contract the uterus and reduce postpartum bleeding, making it a crucial step in managing this situation.

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