While assessing newborns, the nurse should differentiate normal findings from findings which require further evaluation and intervention. Which would be normal newborn findings? Standard Text: Select all that apply
1. Swelling over the occiput that crosses suture lines
2. Tiny white papules located primarily on the nose and chin
3. Tiny red macules and pustules that come and go, primarily on the trunk and extremities
4. When the Moro reflex is elicited, the right arm extends and returns to the body. The left arm remains resting against the chest.
5. Greenish discoloration of skin over the entire body that is not removed by the initial bath
1,2,3
Rationale 1: By crossing suture lines, this finding indicates it is caput succedaneum, a normal finding after vaginal delivery. No further evaluation or treatment is needed.
Rationale 2: This is a description of milia, a normal finding. No further care is required.
Rationale 3: This is a description of erythema toxicum, a normal newborn finding that requires no further treatment.
Rationale 4: This Moro reflex is incomplete. Further evaluation is necessary to determine if there has been injury to the right arm and/or shoulder.
Rationale 5: This is a description of a meconium-stained newborn. The passage of meconium has occurred at a more distant time, leading to the staining. The child will need to be evaluated for meconium aspiration.
Global Rationale:
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