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 C

Explanation

Choice A rationale

Preparing for an emergency cesarean birth may be necessary in some cases of preeclampsia, particularly if there are signs of fetal distress or if the condition is not responding to treatment. However, in this scenario, the client’s symptoms are indicative of magnesium toxicity, not worsening preeclampsia.

Choice B rationale

Positioning the client in Trendelenburg (with the head lower than the feet) is not typically used in the management of preeclampsia or magnesium toxicity.

Choice C rationale

Discontinuing the medication infusion is the correct action in this scenario. The client’s symptoms (respiratory rate of 10/min and absent deep-tendon reflexes) are indicative of magnesium toxicity, a potential complication of magnesium sulfate therapy. Magnesium sulfate is used in the management of preeclampsia to prevent seizures, but it can cause toxicity if the levels become too high. If signs of toxicity occur, the infusion should be discontinued immediately.

Choice D rationale

Assessing maternal blood glucose may be necessary in some cases, particularly if the client has a history of diabetes. However, it is not the priority in this scenario, as the client’s symptoms are indicative of magnesium toxicity, not hyperglycemia.

A. Evaluate the firmness of the uterus. B. Administer oxytocin infusion. C. Obtain a type and crossmatch. D. Initiate oxygen therapy by nonrebreather mask.

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.

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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 with preeclampsia who is being treated with IV magnesium sulfate. The client’s respiratory rate is 10/min and deep-tendon reflexes are absent. What action should the nurse take?

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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

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