A nurse is collecting data from a late preterm newborn.
Which of the following findings should the nurse expect?

Alert, wide-eyed appearance.

Thermal instability.

Hyperglycemia.

Leathery skin.

Answer and Explanation

The Correct Answer is B

Choice A rationale

A late preterm newborn (born between 34 0/7 and 36 6/7 weeks of gestation) often exhibits periods of alertness, but they are also commonly noted to have a sleepy, less sustained alert state compared to a full-term neonate. Their neurological immaturity contributes to poor state regulation and a less vigorous overall response.

Choice B rationale

Thermal instability is an expected finding in late preterm newborns because they have less subcutaneous fat (insulation) than term infants, a higher surface area-to-volume ratio, and immature hypothalamic temperature regulation. This increased vulnerability necessitates careful monitoring and environmental thermoregulation (normal axillary temperature: 36.5°C to 37.3°C).

Choice C rationale

Late preterm newborns are at an increased risk of hypoglycemia (serum glucose ≤ 40 mg/dL) due to inadequate glycogen stores, increased metabolic demands, and immature gluconeogenesis pathways. Hyperglycemia (serum glucose ≥ 125 mg/dL) is not typically expected unless the infant is under high stress or receiving high glucose infusions.

Choice D rationale

Leathery or cracked, dry skin is characteristic of a post-term newborn (born after 42 weeks) due to prolonged exposure to amniotic fluid and desiccation. Late preterm newborns have relatively thin, smooth skin with visible blood vessels because the subcutaneous fat layer is not yet fully developed.

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Correct Answer is C

Explanation

Choice A rationale

Relating the newborn to oneself is a normal process during the "taking-hold" phase of maternal role attainment, typically occurring 2-10 days postpartum, where the mother focuses on the infant and parental role. This involves identifying the newborn as a separate individual while making comparisons, which is an expected psychosocial milestone and not indicative of a concern.

Choice B rationale

Postpartum fatigue and a desire to sleep are common physiological and psychological responses due to the physical exertion of labor, blood loss (normal postpartum blood loss is ≤ 500 mL for vaginal delivery), and interrupted sleep patterns. This is an expected finding and reflects the body's need for rest and recovery, not a pathological psychosocial concern within 48 hours.

Choice C rationale

The absence of desire to feed the newborn or a lack of interest in the infant can be an early indicator of postpartum blues or a more severe mood disorder like postpartum depression. Postpartum blues peaks around day five and resolves within two weeks, but a strong disinterest requires further assessment as it affects bonding and infant care.

Choice D rationale

Discussing the desire for future children indicates a healthy anticipation of a continued family life and is a sign of good adjustment and optimism regarding the maternal role and relationship. This finding is reassuring and signifies positive psychological adaptation rather than a postpartum psychosocial concern within this early timeframe.

A. Weight B. Type of birth C. Apgar scores D. Gestational age E. Heart rate F. Length

Correct Answer is ["A","B","C","D","E","F"]

Explanation

Choice A rationale: Weight is a crucial anthropometric measurement for evaluating a newborn's physical development, nutritional status, and overall health. It is typically recorded in grams or kilograms immediately after birth and monitored regularly. Normal birth weight is generally between 2,500 grams (5 lbs 8 oz) and 4,000 grams (8 lbs 13 oz). Deviations from this range, such as low birth weight, necessitate closer monitoring and specialized care.

Choice B rationale: The type of birth, whether vaginal, operative vaginal (e.g., forceps or vacuum assisted), or cesarean section, is a vital piece of obstetric history. This information is critical as it highlights potential risks the neonate may have encountered, such as transient tachypnea of the newborn following a C-section or trauma associated with a complicated vaginal delivery, and informs future care decisions.

Choice C rationale: The Apgar scores are a rapid, standardized assessment of five physiologic signs (Appearance, Pulse, Grimace, Activity, Respiration) used to evaluate a newborn's transition to extrauterine life. Scores are recorded at one and five minutes after birth. A score between 7 and 10 is considered normal and reassuring, while lower scores indicate the need for immediate intervention and closer observation.

Choice D rationale: Gestational age, typically determined by the last menstrual period and validated by a physical assessment (e.g., Ballard Scale), is essential for classifying the neonate as preterm, full-term, or post-term. It directly correlates with the maturity of organ systems, including the lungs and brain, and dictates the expected range of normal findings and potential risk for specific complications like hyperbilirubinemia or respiratory distress syndrome.

Choice E rationale: The heart rate is a fundamental vital sign, reflecting cardiovascular stability and is a key component of the Apgar score. Normal range for a newborn is typically 110 to 160 beats per minute. A sustained heart rate outside this range, either bradycardia or tachycardia, can signal distress, hypoxia, infection, or other underlying pathology, requiring immediate clinical investigation and intervention.

Choice F rationale: Length (or Crown-Heel length) is an important anthropometric measure recorded alongside weight and head circumference. It helps assess the newborn's growth potential and identify potential intrauterine growth restriction or genetic syndromes when plotted on standardized growth charts. Normal full-term length is generally between 45 and 55 centimeters (17.7 to 21.7 inches).

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A nurse is collecting data from a late preterm newborn. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is 48 hr postpartum. Which of the following findings reported by the client should the nurse identify as a postpartum psychosocial concern?

Correct Answer is C

Explanation

Exhibits A nurse is assisting in the care of a newborn. Which of the following should be included in the electronic medical record (EMR)? Select all that apply.

Correct Answer is ["A","B","C","D","E","F"]

Explanation

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A nurse is collecting data from a late preterm newborn.
Which of the following findings should the nurse expect?