Parent states the extremities of a 2-day-old client extend and return to the previous position when the crib is bumped.
Extending the extremities when the crib is bumped describes the Moro (startle) reflex. It is normal in a client of this age and disappears after 3 to 4 months.
Parent states that the circumcision site of a 3-day-old client is covered with yellowish exudate.
Yellow exudate at the site of a circumcision indicates normal healing in a client of this age.
Parent states that a 4-day-old client who is formula fed has had one stool per day for the past 2 days.
Formula fed infants may pass only one stool per day, while breastfed infants may pass 2 to 5 stools per day.
Parent states that the umbilical cord stump of a 5-day-old client is moist at the base and slightly red. (Correct Answer)
A moist and red umbilical cord stump in a client of this age indicates an infection or other problem with the umbilical stump. The cord should be dry and without redness.
Decision Tree:
This walk-through provides test-taking strategies to determine the correct answer for the different types of questions you will encounter on the NCLEX-RN exam. These strategies are based on the Kaplan Decision Tree (DT) algorithm, a technique that provides a process to determine the correct answer for NCLEX-style questions.
This is a "Who Do You See First" Question.
Terminology that is used here is often phrased as, "Who does the nurse see first?" Use these steps, based on the Kaplan Decision Tree, to determine the correct answer.
STEP 1: Can you identify the topic of the question?
STEPS 2-4: These steps are not relevant to this type of question because you do not need to use the rules for Who Do You See First questions. Move to Step 5.
STEP 5: Read each answer choice and use the Who Do You See First rules.
Who Do You See First Rules:
- Is the client stable or unstable? Eliminate the stable clients.
- Is the client experiencing an expected or unexpected finding? Eliminate expected findings.
- Are the remaining answer options referring to airway, breathing, or circulation (ABCs)? Eliminate each non-priority answer option using the ABCs.
- Are the remaining answers options referring to acute or chronic situations? Eliminate the chronic situation answer options.
- Are the remaining answer options real (actual) or potential problems? Eliminate the potential problem answer options.
- Look at each answer option that remains and ask, what outcome do you want for this client?
- Does this answer option make sense in this situation? If yes, keep this answer option.
- Will this answer option help the client? If yes, keep this answer option.
- Will this answer option hurt the client? If yes, eliminate this answer option.
Unstable vs. Stable
- Parent states the extremities of a 2-day-old client extend and return to the previous position when the crib is bumped. Stable
- Parent states that the circumcision site of a 3-day-old client is covered with yellowish exudate. Stable
- Parent states that a 4-day-old client who is formula fed has had one stool per day for the past 2 days. Stable
- Parent states that the umbilical cord stump of a 5-day-old client is moist at the base and slightly red. Stable
Unexpected vs. Expected
- Parent states the extremities of a 2-day-old client extend and return to the previous position when the crib is bumped. Expected. Eliminate.
- Parent states that the circumcision site of a 3-day-old client is covered with yellowish exudate. Expected. Eliminate.
- Parent states that a 4-day-old client who is formula fed has had one stool per day for the past 2 days. Expected. Eliminate.
- Parent states that the umbilical cord stump of a 5-day-old client is moist at the base and slightly red. Unexpected
Select the best choice
Is #4 the correct answer? Yes, this client is unstable. You must return this call first in order to ensure safety of the client.
Does #4 make sense? Yes, the newborn is unstable and you must gain further information about the client?s status. Bleeding, drainage, redness, or foul odor from the cord stump are abnormal.
