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

While providing age-appropriate stimulation is important for all newborns, it is not the priority nursing goal in caring for a newborn with a myelomeningocele awaiting surgery.

Choice B rationale

Educating the parents about the defect is an important part of care, but it is not the priority nursing goal. The immediate physical needs of the newborn take precedence.

Choice C rationale

This is the correct answer. The sac covering the exposed neural tissue must be carefully protected to prevent infection and further damage. Therefore, maintaining the integrity of the sac is the priority nursing goal.

Choice D rationale

Promoting maternal-infant bonding is important, but it is not the priority nursing goal in caring for a newborn with a myelomeningocele awaiting surgery.

A. Perineal pad clots B. Pelvic pain C. Boggy uterus D. Breast Engorgement

Correct Answer is C

Explanation

Choice A rationale:
Perineal pad clots are not the greatest risk for this patient. While it’s important to monitor the amount and type of lochia, the nurse’s notes indicate that the patient has a moderate amount of lochia rubra, which is normal within the first few days postpartum. Large clots could indicate a problem such as a retained placental fragment, but this is not mentioned in
the scenario.
Choice B rationale:
Pelvic pain is a common complaint after childbirth due to uterine contractions, especially during breastfeeding, and usually resolves within a few days. The patient’s pain is rated as 4 on a scale of 0 to 10, which is considered moderate. While it’s important to manage the patient’s pain, it’s not the greatest risk in this scenario.
Choice C rationale:
A boggy uterus poses the greatest risk for this patient. A boggy or soft uterus indicates uterine atony, which is a lack of normal muscle tone that can lead to excessive bleeding. This is a serious condition that can lead to postpartum hemorrhage if not treated promptly. The nurse’s notes indicate that the patient’s fundus is boggy and located above the umbilicus, which is a concern. The fundus should be firm and gradually descend into the pelvis within the first few days postpartum.
Choice D rationale:
Breast engorgement is a common discomfort that occurs when the breasts are overly full with milk. It typically occurs within the first week postpartum as the milk supply increases. The nurse’s notes indicate that the patient’s breasts are soft, warm, and tender to touch, which is normal. While it’s important to manage the patient’s comfort, breast
engorgement is not the greatest risk in this scenario.

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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 newborn who has myelomeningocele. Which of the following nursing goals has the priority in the care of this infant?

Correct Answer is C

Explanation

Choice B rationale

Choice C rationale

Choice D rationale

A nurse is caring for a patient who is 36 hours postpartum. Exhibits After reviewing the information in the patient’s medical record, which of the following complications pose a greater risk for the patient?

Correct Answer is C

Explanation

Which of the following expectations about postpartum changes has the client correctly understood?

A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block?

A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client’s bladder is distended?

A nurse is caring for a client who is a primigravida, at term, and having contractions but is unsure if she is in labor. Which of the following should the nurse recognize as a sign of true labor?

A nurse is attending to a client who is receiving opioid epidural analgesia during labor. Which of the following observations should the nurse prioritize?

A home health nurse is teaching a client who is breastfeeding about managing breast engorgement. Which of the following client statements indicates understanding of the teaching?

A nurse is admitting an 8-hour-old, term newborn following a cesarean birth. The nurse observes that the newborn’s skin is yellow. This finding indicates the newborn is experiencing a complication related to which of the following?