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 .
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A fundus that is palpable to the right of the midline can indicate a distended bladder. After childbirth, it’s common for women to have difficulty emptying their bladder. If the bladder becomes too full, it can push the uterus to one side.
Choice B rationale
Frequent uterine contractions are not typically associated with a distended bladder. After childbirth, it’s normal for women to experience contractions as the uterus begins to shrink back to its pre-pregnancy size.
Choice C rationale
Increased thirst is not typically a sign of a distended bladder. It’s common for women to feel thirsty as their body adjusts after childbirth.
Choice D rationale
Less than 2.5 cm of rubra lochia on the perineal pad is not typically a sign of a distended bladder. Lochia is the vaginal discharge women experience after childbirth. It’s not related to bladder function.
Correct Answer is A
Explanation
Choice A rationale
The nurse’s response, “You seem scared to talk to your parents,” is an empathetic response that validates the client’s feelings and encourages further communication. It’s important for the nurse to provide emotional support and help the client explore her feelings about the situation. The nurse can also provide information about confidentiality laws and discuss potential outcomes of various decisions.
Choice B rationale
Telling the client that her parents will have to be told why she is being admitted may not be accurate depending on the age of the client and local laws regarding minor’s rights to privacy in healthcare. It’s crucial to respect the client’s autonomy and privacy.
Choice C rationale
While it’s possible that the parents might understand, suggesting this puts pressure on the client to disclose her condition to her parents. The nurse should instead focus on supporting the client in making her own decision about disclosure.
Choice D rationale
Offering to tell the parents for the client could undermine the client’s autonomy and may not be legally permissible without the client’s consent. The nurse should instead focus on helping the client explore her options and come to her own decision.
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