A nurse is collecting data from a newborn who is 1 hr old and was born at 43 weeks of gestation. Which of the following findings should the nurse expect? (Select all that apply.)

Dry, cracked skin

Hypotonia

Excessive lanugo

Absent vernix

Long, hard nails

Answer and Explanation

Correct Answer : B,C,E

A)   Incorrect- Dry, cracked skin is not typically associated with a newborn born at 43 weeks of gestation. It's more common in post-term babies.
B)   Correct - Hypotonia (low muscle tone) is a possible finding in post-term newborns due to the aging placenta and potential decrease in amniotic fluid.
C)   Correct - Excessive lanugo (fine, downy hair) is more likely to be present in post-term babies as they have less vernix to protect their skin.
D)   Incorrect- Absent vernix might be more characteristic of a post-term newborn, but its presence or absence varies widely.
E)   Correct - Long, hard nails can be a characteristic of post-term babies, as they have had more time for nail growth in the womb.

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Correct Answer is C

Explanation

A) Incorrect- Administering medication into the deltoid muscle is not typically done in newborns. Phytonadione is given intramuscularly, usually in the vastus lateralis muscle, not the deltoid muscle.
B) Incorrect- Phytonadione should be given within 1 hour of birth, not 12 hours after birth. Delaying the administration increases the risk of bleeding complications.
C) Correct- The size of the needle is important for the newborn's comfort, A 25-gauge needle is the appropriate size for administering phytonadione to a newborn. A smaller needle may not deliver the medication adequately, and a larger needle may cause more tissue damage and bleeding.
D) Incorrect- The mother's Rh factor is irrelevant for the administration of phytonadione.

Rh factor affects the risk of hemolytic disease in the newborn, which is a different condition from hemorrhagic disease.

A. Instruct the client that oxytocin is administered during the procedure. B. Inform the client that this procedure assists in indicating Down syndrome. C. Assist the client to a lateral tilt position prior to the procedure. D. Ensure the client has been NPO for 6 hr prior to the procedure.

Correct Answer is C

Explanation

A) Incorrect- Oxytocin is not typically administered during a nonstress test.

B) Incorrect- A nonstress test is used to assess fetal well-being and does not indicate Down syndrome.
C) Correct - A lateral tilt position (usually left lateral tilt) is recommended during a nonstress test to prevent compression of the vena cava and maintain proper blood flow to the uterus, which can optimize fetal heart rate monitoring.
D) Incorrect- NPO status is not typically required for a nonstress test. Nonstress tests are non-invasive and do not involve fasting.

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A nurse is collecting data from a newborn who is 1 hr old and was born at 43 weeks of gestation. Which of the following findings should the nurse expect? (Select all that apply.)

Nursing Test Bank

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