A nurse is caring for a newborn with a gestational age of 42 weeks.
Which finding would the nurse expect during the assessment of this newborn?
Sole creases that cover only the anterior one-third of the foot.
Abundance of vernix caseosa in the skin creases.
Dryness and flaking of the skin on the hands and feet.
Large amount of fine, downy hair on the back and shoulders.
The Correct Answer is C
The correct answer is choice C. Dryness and flaking of the skin on the hands and feet. This is because a newborn with a gestational age of 42 weeks is considered post-mature and has lost the protective vernix caseosa that covers the skin of most newborns. The skin of a post-mature newborn is also more exposed to the amniotic fluid, which can cause it to peel and crack.
Choice A is wrong because sole creases that cover only the anterior one-third of the foot are characteristic of a preterm newborn, not a post-mature one.
Choice B is wrong because vernix caseosa is abundant in preterm newborns and decreases as gestational age increases. A post-mature newborn would have little or no vernix caseosa on the skin.
Choice D is wrong because a large amount of fine, downy hair (lanugo) on the back and shoulders is also typical of a preterm newborn, not a post-mature one. Lanugo usually disappears by 36 weeks of gestation. A post-mature newborn would have little or no lanugo on the body.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Remind the patient that the nurse will stay with her during the examination.
This measure would help reduce the patient’s anxiety by providing emotional support and reassurance.
The patient may feel scared, embarrassed, or vulnerable during the pelvic examination, especially since she is young and pregnant.
Having a trusted person with her can help her cope with these feelings.
Choice A is wrong because it may imply that the examination will be painful and increase the patient’s anxiety.
Choice B is wrong because it may make the patient feel like she is not being treated as an individual and that her concerns are not valid.
Choice D is wrong because it may make the patient feel rushed or pressured and not allow her to ask questions or express her feelings.
Correct Answer is C
Explanation
The correct answer is choice C. Have a suction catheter available for use at delivery.This is because meconium-stained amniotic fluid indicates that the fetus has passed meconium (first stool) before birth, which can be a sign of fetal distress or hypoxia.Meconium can block the airways and cause breathing problems for the newborn, so suctioning the mouth and nose (or the trachea if needed) is important to prevent meconium aspiration syndrome.
Choice A is wrong because taking the mother’s vital signs every 15 minutes is not a specific intervention for meconium-stained amniotic fluid.
Vital signs should be monitored regularly during labor regardless of the fluid color.
Choice B is wrong because sending a specimen of the fluid to the laboratory for analysis is not a priority action.The color and consistency of the fluid can be observed by the nurse and documented.
The laboratory analysis will not change the immediate management of the newborn.
Choice D is wrong because preparing a slide of the fluid for fern testing is not relevant for meconium-stained amniotic fluid.
Fern testing is used to confirm the rupture of membranes by detecting a fern-like pattern of amniotic fluid under a microscope.It is not useful for assessing the presence or severity of meconium-stained amniotic fluid.
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