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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Fetal breathing. The biophysical profile assesses fetal breathing movements as one of the components indicating fetal well-being.
B. Fetal neck translucency. This is not part of the biophysical profile; it is typically assessed during first-trimester screening for chromosomal abnormalities.
C. Fetal motion. Fetal movements are another component of the biophysical profile, reflecting the fetal central nervous system integrity and oxygenation.
D. Amniotic fluid volume. The assessment of amniotic fluid volume is crucial in determining fetal well-being and adequate fetal renal function.
E. Fetal gender. Gender is not assessed as part of the biophysical profile; the test focuses on fetal physiological parameters related to well-being.
Correct Answer is A
Explanation
A. Administer parenteral antibiotics. The primary concern with premature rupture of membranes (PROM) is the risk of infection, so administering antibiotics is crucial to prevent infection in both the mother and fetus.
B. Prepare for delivery. Without signs of labor, the focus is on preventing infection and monitoring, not immediate delivery.
C. Provide emotional support. While important, the priority intervention is preventing infection.
D. Assess cervical dilation every 6 hours. Routine cervical checks are not typically necessary unless there are signs of labor or other indications.
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