A nurse is preparing to assess a newborn who is postmature.
Which of the following findings should the nurse expect? (Select all that apply.)
Abundant lanugo
Positive Moro reflex
Vernix in the folds and creases
Short, soft fingernails
Cracked, peeling skin
Correct Answer : B,E
Choice A rationale
Abundant lanugo, which is fine hair, is not typically seen in postmature babies. It is more common in babies who are born prematurely.
Choice B rationale
A positive Moro reflex is a normal finding in newborns, including those who are postmature, indicating a healthy neurological response.
Choice C rationale
Vernix, a white creamy substance that protects the baby’s skin in the womb, is usually absent or very scant in postmature babies.
Choice D rationale
Short, soft fingernails are not a specific sign of postmaturity. Newborns’ fingernails can vary, and they often grow quickly after birth.
Choice E rationale
Cracked, peeling skin is commonly seen in postmature babies. Their skin can often appear dry and wrinkled.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Fundus at umbilicus is expected 4 hours postpartum, indicating normal uterine involution. No abnormal bleeding or uterine atony is implied, so it’s not a priority concern.
Choice B rationale: Deep tendon reflexes 4+ are hyperactive and signal increased neuromuscular irritability, placing the client at high risk for seizures due to preeclampsia. Immediate magnesium sulfate therapy may be required.
Choice C rationale: Saturated pad in 30 minutes suggests heavy lochia but is not yet classified as hemorrhage. Requires monitoring, but seizure risk from preeclampsia is more immediately life-threatening.
Choice D rationale: Approximated episiotomy edges indicate proper healing and no infection or dehiscence. This is a normal finding and does not require urgent intervention.
Correct Answer is A
Explanation
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