A nurse is completing a newborn gestational age assessment. Which of the following findings should be recorded as part of this assessment on the newborn?
Plantar creases cover 2/3 of sole
Acrocyanosis of hands and feet
Anterior fontanel soft and level
Vernix caseosa in inguinal creases
The Correct Answer is A
- A: Plantar creases covering 2/3 of the sole is indicative of a more mature newborn, which is a significant finding in assessing gestational age.
- B: Acrocyanosis of hands and feet is a common finding in the first few days after birth and is not specifically related to gestational age.
- C: The condition of the anterior fontanel being soft and level is a normal finding and does not contribute to the assessment of gestational age.
- D: The presence of vernix caseosa in inguinal creases can be seen in both preterm and full-term newborns, thus it is not a specific indicator of gestational age.
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Related Questions
Correct Answer is B
Explanation
A. An apical heart rate of 130/min is within the normal range for a newborn and does not require further assessment by the provider.
B. Documenting this as an expected finding is appropriate as the normal range for a newborn's heart rate is typically between 120-160 beats per minute.
C. Asking another nurse to verify the heart rate may delay care unnecessarily, as the rate is within the expected range.
D. There is no indication to prepare the newborn for transport to the NICU based solely on an apical heart rate of 130/min, as this is within the normal range.
Correct Answer is A
Explanation
A. Uterine atony is the most common cause of postpartum hemorrhage and is more likely to occur after a delivery of a large infant or in cases of rapid or prolonged labor.
B. Thrombophlebitis is a risk after childbirth, especially in clients who have undergone cesarean delivery or who have other risk factors such as prolonged immobility, but it is not directly related to the size of the newborn.
C. Puerperal infection is a risk following childbirth, but it is not directly related to the size of the newborn.
D. Retained placental fragments can lead to postpartum hemorrhage, but the size of the newborn is not a direct risk factor for this complication.
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