A nurse is caring for a client having a biophysical profile.
The client asks what the test is for.
What should the nurse include in the response? (Select all that apply.)
Fetal breathing.
Fetal motion.
Amniotic fluid volume assessment.
Fetal neck translucency.
Fetal gender.
Correct Answer : A,B,C
Choice A rationale
Cracked, peeling skin is typical of postmature infants due to prolonged exposure to amniotic fluid. Reduced vernix caseosa, which normally protects the skin, exacerbates this peeling.
Choice B rationale
A positive Moro reflex is an expected neurologic finding in postmature infants, demonstrating an intact central nervous system. Persistence or absence may indicate neurologic compromise requiring further evaluation.
Choice C rationale
Creases covering the soles of the feet are common in postmature infants due to advanced physical maturity. Increased plantar creasing correlates with gestational age and tissue development.
Choice D rationale
Postmature infants often have long, hardened fingernails rather than short, soft nails. Extended gestation promotes additional growth, distinguishing them from premature or term neonates.
Choice E rationale
Vernix is typically absent or minimal in postmature infants due to its absorption after 40 weeks of gestation. Limited vernix increases the risk of skin desquamation and irritation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Elevating the head reduces the risk of aspiration by preventing stomach contents, including gastric juices, from entering the lungs. This position is essential for infants with tracheoesophageal fistula due to the abnormal connection between the trachea and esophagus, which increases aspiration risk.
Choice B rationale
Facilitating food digestion is not the primary goal of this positioning. Gastric motility and digestion are unaffected by head elevation, making this rationale irrelevant to the question. Therefore, this is not the correct choice.
Choice C rationale
While head elevation can improve breathing by reducing diaphragm compression, the primary purpose in this context is to prevent aspiration. Lung expansion is a secondary benefit, but it is not the main reason for this position.
Choice D rationale
Reducing stomach pressure is not the key reason for elevating the head in this case. Although head elevation can minimize intra-abdominal pressure, this rationale does not address the critical concern of preventing aspiration in tracheoesophageal fistula. .
Correct Answer is D
Explanation
Choice A rationale
The Oucher scale uses photographic images or numerical scales and is appropriate for older children who can visually correlate their pain level with the provided scale. It is not ideal for younger children or those unable to understand numerical or photographic representations.
Choice B rationale
The Visual Analog Scale requires a more mature understanding of concepts such as gradients and is suitable for older children and adults. It is not an appropriate tool for a 5-year-old as their cognitive development may limit the accurate use of this scale.
Choice C rationale
The FLACC scale assesses pain based on behavioral observations and is ideal for non-verbal or very young children. However, a 5-year-old can generally articulate their pain or utilize pictorial representations, making other scales more suitable.
Choice D rationale
The FACES scale, featuring cartoonish faces representing varying pain levels, is a validated tool for children as young as 3 years old. Its simplicity and visual clarity make it an effective and age-appropriate method for a 5-year-old to communicate their pain level.
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