Nokea
What does the nurse explain this transitory skin discoloration is called?
- A. Epstein's pearls
- B. Milia
- C. Stork bites
- D. Mongolian spots
Correct Answer: D
Rationale: Bluish skin discoloration over the sacral area of a newborn is a transitory condition called Mongolian spots.
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While inspecting a newborn's head, the nurse identifies a swelling of the scalp that does not cross the suture line. How would the nurse refer to this finding when documenting?
- A. Molding
- B. Caput succedaneum
- C. Cephalohematoma
- D. Enlarged fontanelle
Correct Answer: C
Rationale: A cephalohematoma is caused by a collection of blood beneath the periosteum of the cranial bone and does not cross the suture line.
What is the nurse's most helpful response when instructing the parents?
- A. Contact a pediatric dermatologist for topical medication.
- B. Squeeze out the white material after cleansing the face.
- C. Wash the infant's face with a mild astringent several times a day.
- D. Leave the milia alone; it will disappear spontaneously. No treatment is needed.
Correct Answer: D
Rationale: Milia require no treatment and will disappear spontaneously.
The nurse takes into consideration that newborns are especially prone to dehydration because of which aspects of their physiology?
- A. Small glomeruli
- B. Minimal renal blood flow
- C. Inactive gastrointestinal (GI) tract
- D. Excessive fluid loss from the sweat glands
- E. Immature renal tubules that do not concentrate urine
Correct Answer: A,B,E
Rationale: Newborns are prone to dehydration due to small glomeruli, minimal renal blood flow, and immature renal tubules that do not concentrate urine effectively.
What will the nurse expect when assessing the anterior fontanelle of a healthy, full-term newborn?
- A. Depressed and sunken
- B. Triangular shaped
- C. Smaller than the posterior fontanelle
- D. Open and diamond shaped
Correct Answer: D
Rationale: The anterior fontanelle is diamond shaped, located at the junction of the two parietal and two frontal bones, and should not be raised or sunken. It closes between 12 and 18 months.
Which of the following should be brought to the physician's attention first?
- A. White blood cell count of 18,000
- B. Hemoglobin of 18.5
- C. Hematocrit of 56
- D. Bilirubin of 15
Correct Answer: D
Rationale: A bilirubin level of 15 is elevated and requires immediate further investigation.