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 B
Explanation
This is because late fetal heart rate decelerations are a sign of uteroplacental insufficiency, which means that the placenta is not delivering enough oxygen and nutrients to the fetus.Oxytocin can cause uterine tachysystole, which is excessive and frequent contractions that reduce blood flow to the placenta.Therefore, stopping the oxytocin infusion can help improve placental perfusion and fetal oxygenation.
Choice A is wrong because documenting the findings is not a priority action in this situation.
The nurse should first intervene to address the cause of late decelerations and then document the actions and outcomes.
Choice C is wrong because raising the head of the patient’s bed 30 degrees does not directly affect the placental blood flow or fetal oxygenation.
It may help with maternal comfort and breathing, but it is not an essential action for late decelerations.
Choice D is wrong because notifying the health care provider is not the first action to take.The nurse should first attempt to correct the cause of late decelerations by pausing the oxytocin infusion and then notify the health care provider if there is no improvement or if there are other signs of fetal distress.
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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