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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

The correct answer is choice A and it indicates fetal distress because it is a sign oflate deceleration.Late decelerations are due touteroplacental insufficiencyas the result of decreased blood flow and oxygen to the fetus during the uterine contractions.This causeshypoxemiaand can lead to fetal acidosis and neurological damage.

Choice B is wrong because it indicates anormal variabilityin the fetal heart rate, which reflects a healthy autonomic nervous system.A normal fetal heart rate is 120-160 beats per minute.

Choice C is wrong because it indicates anearly accelerationin the fetal heart rate, which is a benign finding that may occur with fetal movement or stimulation.

Choice D is wrong because it indicates anearly decelerationin the fetal heart rate, which is a normal response to fetal head compression during contractions.

It does not indicate fetal distress.

Normal ranges for fetal heart rate patterns are:

• Baseline: 120-160 beats per minute

• Variability: 6-25 beats per minute

• Accelerations: at least 15 beats per minute above baseline for at least 15 seconds

• Decelerations: none or early (mirror contractions)

A. Rubella immunization should be given in the early postpartum period. B. Gamma globulin should be given when the client is admitted in labor. C. Gamma globulin should be given at next visit. D. Rubella immunization should be given at next visit.

Correct Answer is A

Explanation

Rubella immunization should be given in the early postpartum period.This is because rubella infection during pregnancy can cause serious birth defects or miscarriage, and rubella vaccine is contraindicated during pregnancy.Therefore, the best time to vaccinate a woman who is not immune to rubella is after she delivers her baby.

Choice B is wrong because gamma globulin is not effective for preventing rubella infection or congenital rubella syndrome (CRS).Gamma globulin is a preparation of antibodies that can provide temporary protection against some infections, but it does not induce lasting immunity.

Choice C is wrong because gamma globulin should not be given at the next visit for the same reason as choice B.Moreover, gamma globulin can interfere with the response to live vaccines such as rubella vaccine, so it should not be given within 3 months before or after vaccination.

Choice D is wrong because rubella immunization should not be given at the next visit or during pregnancy, as it can pose a risk to the fetus.Rubella vaccine is a live attenuated virus vaccine that can cross the placenta and infect the fetus.The risk of CRS from vaccination during pregnancy is low, but it cannot be ruled out completely.Therefore, women who receive rubella vaccine should avoid pregnancy for at least 4 weeks after vaccination.

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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?

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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?