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. Educating the parents about the defect is important for their understanding and involvement in the care of the newborn, but it is not the priority when the infant has a myelomeningocele.
B. Maintaining the integrity of the sac is the priority goal in the care of a newborn with myelomeningocele to prevent infection and protect the exposed neural tissue.
C. Providing age-appropriate stimulation is important for the overall development of the newborn but is not the priority when the infant has a myelomeningocele.
D. Promoting maternal-infant bonding is essential for the emotional well-being of both the
mother and the newborn, but it is not the priority when immediate physical care needs exist, such as maintaining the integrity of the sac.
Correct Answer is B
Explanation
A. Pain following a cesarean birth is important to address, but it may not indicate an urgent need for assessment compared to other potential complications.
B. A client with preeclampsia requires close monitoring of blood pressure to prevent
complications such as eclampsia, which can lead to seizures and other serious consequences. An elevated blood pressure reading warrants immediate attention.
C. A client scheduled for discharge following a laparoscopic tubal ligation is stable and can likely wait for assessment until after higher-priority clients have been seen.
D. While it's important to monitor for bleeding after a vaginal birth, the absence of bleeding reported by a client 24 hours postpartum may not indicate an immediate need for assessment compared to the potential urgency of managing preeclampsia.
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