A nurse is preparing to assess a newborn who is postmature. Which of the following findings should the nurse expect?

Cracked, peeling skin

Abundant lanugo

Short, soft fingernails

Abundant vernix .

Answer and Explanation

The Correct Answer is A

Choice A rationale: A postmature newborn, or one born after 42 weeks of gestation, is likely to exhibit cracked, peeling skin due to the prolonged exposure to amniotic fluid and the absence of vernix. This makes Choice A the correct answer, as it reflects the expected findings for a postmature newborn.

Choice B rationale: Abundant lanugo is typically seen in preterm infants, not postmature infants. Lanugo is a fine, downy hair that covers the fetus and usually disappears by 37 weeks of gestation. Therefore, Choice B is not an expected finding for a postmature newborn.

Choice C rationale: Short, soft fingernails are characteristic of preterm infants. In postmature infants, fingernails are generally long and may extend beyond the fingertips due to prolonged gestation. This makes Choice C an incorrect answer for the expected findings of a postmature newborn.

Choice D rationale: Abundant vernix is typically seen in preterm and term infants. Vernix is a white, cheesy substance that covers the fetal skin to protect it from amniotic fluid. Postmature infants usually have minimal to no vernix present, as it has already been absorbed. Therefore, Choice D is not an expected finding for a postmature newborn.

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Correct Answer is A

Explanation

Choice A rationale

If a nurse notes that a client’s blood pressure is 60/50 mm Hg two hours after giving birth, the first action should be to evaluate the firmness of the uterus. This is because a soft or “boggy” uterus could indicate uterine atony, a condition where the uterus fails to contract after delivery, leading to excessive bleeding and a drop in blood pressure.

Choice B rationale

Administering oxytocin infusion can help stimulate uterine contractions and control postpartum bleeding. However, it is not the first action to take. The nurse should first assess the firmness of the uterus.

Choice C rationale

Obtaining a type and crossmatch is important if a blood transfusion is required. However, this is not the first action. The nurse should first assess the firmness of the uterus.

Choice D rationale

Initiating oxygen therapy can help ensure adequate oxygen supply to the tissues, but it is not the first action. The nurse should first assess the firmness of the uterus.

A. Ask the client if she has considered harming her newborn. B. Reinforce postpartum and newborn care discharge teaching. C. Assist the family to identify prior use of positive coping skills in family crises. D. Anticipate a prescription by the provider for an antidepressant.

Correct Answer is A

Explanation

Choice A rationale

If a client reports feeling down and sad, having no energy, and wanting to cry, the nurse’s priority action should be to ask the client if she has considered harming her newborn. This is because these symptoms may indicate postpartum depression, a serious condition that can lead to harm to both the mother and the baby if left untreated.

Choice B rationale

While reinforcing postpartum and newborn care discharge teaching is important, it is not the priority action in this situation. The client’s emotional health needs to be addressed first.

Choice C rationale

Assisting the family to identify prior use of positive coping skills in family crises can be helpful, but it is not the priority action in this situation. The client’s immediate emotional health needs to be addressed first.

Choice D rationale

Anticipating a prescription by the provider for an antidepressant may be part of the treatment plan for this client, but it is not the priority action. The nurse first needs to assess the safety of the client and her newborn.

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A nurse is preparing to assess a newborn who is postmature. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who gave birth 2 hours ago. The nurse notes that the client’s blood pressure is 60/50 mm Hg. What should be the nurse’s first action?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling down and sad, having no energy, and wanting to cry. What should be the nurse’s priority action?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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