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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A BP of 105/62 mm Hg is within the expected normal range for a postpartum adolescent client. A typical normotensive range is 90-140 mm Hg systolic and 60-90 mm Hg diastolic. Opioids like morphine can cause mild hypotension, but this reading doesn't indicate an immediate, life-threatening crisis.
Choice B rationale
A respiratory rate of 11/min is the priority because it signifies respiratory depression, a life-threatening, dose-related adverse effect of opioid analgesics like morphine. The normal respiratory rate for an adolescent is 12-20 breaths/min. Rates ≤ 12/min require immediate intervention, including potential administration of an opioid antagonist like naloxone.
Choice C rationale
Urinary retention is a common side effect of opioid administration due to increased bladder sphincter tone and reduced detrusor muscle contractility. While uncomfortable and potentially leading to urinary tract infection or bladder damage, it is less acute and life-threatening than respiratory depression.
Choice D rationale
Blurred vision can be an uncommon side effect of morphine, possibly due to miosis (pupil constriction) or minor changes in intraocular pressure. This finding requires further assessment but is a non-life-threatening adverse effect and does not pose the immediate threat of respiratory depression.
Correct Answer is B
Explanation
Choice A rationale
Fetal hemolytic disease, such as erythroblastosis fetalis, involves the destruction of fetal red blood cells, often due to maternal alloimmunization, like Rh incompatibility. This condition is primarily assessed using other tests, such as analysis of bilirubin levels in the amniotic fluid (measured by Delta OD 450) or fetal blood sampling, which provides a direct measure of fetal anemia, not the L/S ratio. Normal fetal Hct is 35% to 55%.
Choice B rationale
The Lecithin/Sphingomyelin (L/S) ratio is a biochemical assay performed on amniotic fluid to determine fetal pulmonary maturity. Lecithin (phosphatidylcholine) production increases significantly after 32 weeks gestation, while Sphingomyelin remains constant. A ratio of 2: or greater indicates adequate surfactant production, minimizing the risk of Respiratory Distress Syndrome (RDS) in the newborn, although in diabetic pregnancies, a higher ratio of 3: may be needed.
Choice C rationale
Fetal heart activity, including the fetal heart rate and its variability, is primarily assessed using Doppler ultrasound and cardiotocography (Nonstress Test or Contraction Stress Test). These methods directly evaluate the electromechanical function of the fetal myocardium and the integrity of the feto-placental unit, independent of the L/S ratio measurement. The normal FHR is 110 to 160 beats/min.
Choice D rationale
Macrosomia refers to a fetus with an excessive birth weight, typically defined as greater than 4000 g or 4500 g. Macrosomia is assessed through serial fundal height measurements, ultrasound biometry (head circumference, abdominal circumference, femur length) to estimate fetal weight, and clinical palpation, not by analysis of the L/S ratio from amniotic fluid.
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