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 A
Explanation
The correct answer is choice A. Maintaining the infants’ airways is the nurse’s priority when caring for a set of twins delivered by cesarean delivery.This is because twins are more likely to be born early and need special care after birth than single babies.They may have breathing difficulties or low oxygen levels and require oxygen therapy or ventilation.
The nurse should assess the infants’ respiratory status and intervene as needed.
Choice B is wrong because keeping the infants in a warm, draft-free environment is important but not as urgent as ensuring their airways are clear and they are breathing well.Premature twins may have trouble regulating their body temperature and need to be kept warm, but this can be done after their airways are secured.
Choice C is wrong because placing identification bands on the infants is a standard procedure but not a priority.
The nurse should make sure the infants are correctly identified and matched with their mother, but this can be done after their vital signs are stable.
Choice D is wrong because monitoring the infants’ vital signs is also important but not as urgent as maintaining their airways.
The nurse should check the infants’ heart rate, blood pressure, temperature and blood sugar levels regularly, but this can be done after their respiratory status is assessed and managed.
Normal ranges for vital signs in newborns are:
• Heart rate: 100 to 160 beats per minute
• Blood pressure: 50 to 75 mm Hg systolic and 30 to 45 mm Hg diastolic
• Temperature: 36.5 to 37.5°C (97.7 to 99.5°F)
• Blood sugar: 40 to 80 mg/dL
Correct Answer is A
Explanation
he correct answer is choice A. “Instead of having eggs, I am eating yogurt for breakfast.” This statement shows a need for further instruction because eggs are a good source of protein and yogurt is not.
Yogurt is a dairy product that contains mostly carbohydrates and some fat.
Eggs are an animal product that contains mostly protein and some fat.
Protein is important for building and repairing tissues in the body.
Choice B is correct because adding powdered milk to skim milk increases the protein content of the drink.
Powdered milk is a dairy product that contains protein, carbohydrates and fat.
Skim milk is a dairy product that contains protein and carbohydrates but no fat.
Choice C is correct because peanut butter is a good source of protein and healthy fats.
Peanut butter is a plant product that contains protein, fat and some carbohydrates.
Crackers are a grain product that contains mostly carbohydrates and some protein.
Choice D is correct because cream of tomato soup is a good source of protein and calories.
Cream of tomato soup is a processed food that contains tomatoes, cream, flour and seasonings.
Tomatoes are a vegetable that contains mostly water and some carbohydrates.
Cream is a dairy product that contains mostly fat and some protein.
Flour is a grain product that contains mostly carbohydrates and some protein.
Seasonings are herbs and spices that contain mostly flavor and some nutrients.
The normal range of protein intake for adults is 0.8 to 1 gram per kilogram of body weight per day.
This means that an adult who weighs 70 kilograms should consume about 56 to 70 grams of protein per day.
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