A nurse is assessing a postmature infant. Which of the following findings would the nurse expect? (Select All that Apply.)

Vernix in the folds and creases

Short, soft fingernails

Abundant lanugo

Cracked, peeling skin

Creases covering soles of feet

Positive moro reflex

Answer and Explanation

Correct Answer : D,E,F

A. Vernix in the folds and creases. Vernix caseosa is typically decreased or absent in postmature infants.
B. Short, soft fingernails. Postmature infants usually have long, hard fingernails.
C. Abundant lanugo. Lanugo (fine body hair) is usually less or absent in postmature infants, which is more typical of preterm infants.
D. Cracked, peeling skin. Postmature infants often have dry, peeling skin due to prolonged exposure to amniotic fluid.
E. Creases covering soles of feet. This is a sign of maturity; postmature infants have more developed skin creases on the soles of their feet.
F. Positive moro reflex. This is a normal reflex seen in infants and should be present in a postmature infant.

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Correct Answer is D

Explanation

A. Administer Oxytocin IV per MD orders. This may be done after attempting fundal massage to help firm the uterus, but massage is the first step.
B. Notify the healthcare provider. This would be done if the fundus does not respond to massage or if excessive bleeding continues, but not before attempting to firm the fundus.
C. Document the fundal height and consistency. Documentation is important but should occur after addressing the immediate issue of a soft fundus to prevent hemorrhage.
D. Massage the fundus until it firms. The immediate action should be to massage the uterus to promote contraction and reduce bleeding. A soft, spongy uterus indicates uterine atony, which can lead to hemorrhage.

A. I'll expect the plastic ring to fall off by itself within a week B. I'll apply the petroleum jelly to his penis with diaper changes C. I'll make sure his diaper is loose in the front D. I'll wash his penis with warm water and mild soap each day E. I'll call the doctor if I see any bleeding

Correct Answer is ["A","C","E"]

Explanation

A. I'll expect the plastic ring to fall off by itself within a week. This is correct; the Plastibell ring typically falls off within 5-8 days.
B. I'll apply petroleum jelly to his penis with diaper changes. Incorrect for Plastibell, because the plastic ring itself protects the site, and petroleum jelly can interfere with healing.
C. I'll make sure his diaper is loose in the front. This helps avoid pressure and irritation on the circumcised area.
D. I'll wash his penis with warm water and mild soap each day. Incorrect; the area should be kept clean but only water should be used to avoid irritation.
E. I'll call the doctor if I see any bleeding. Any significant bleeding should be reported to the healthcare provider immediately.

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A nurse is assessing a postmature infant. Which of the following findings would the nurse expect? (Select All that Apply.)

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A nurse is assessing the fundus of a postpartum patient one day after delivery and notes that the fundus is soft and spongy. Which is the first nursing intervention to preform?

Correct Answer is D

Explanation

A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with a Plastibell technique. Which of the following client statements indicates an understanding of her son's circumcision care? (Select All that Apply.)

Correct Answer is ["A","C","E"]

Explanation

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