A nurse is preparing to examine a post-term newborn immediately following delivery. Which of the following findings should she expect to observe? (Select all that apply.).
Moro reflex.
Vernix in the folds and creases.
Abundant lanugo.
Heel to ear maneuverability.
Correct Answer : A
Choice A rationale:
The Moro reflex is a normal finding in newborns, including those born post-term. It is a primitive reflex that should be present and indicates a healthy neurological system.
Choice B rationale:
Vernix, a protective white substance that coats the skin in utero, is typically absent or minimal in post-term newborns due to its decreased production as gestation progresses. Therefore, it would not be expected in a post-term infant.
Choice C rationale:
Lanugo, the fine hair covering a newborn's body, is usually present in greater amounts in preterm infants. By the time a newborn is post-term, lanugo is typically sparse or absent, making it an unlikely finding.
Choice D rationale:
This maneuver assesses the flexibility of the newborn's joints. Post-term infants tend to have reduced flexibility and increased muscle tone, making this maneuver more difficult or restricted in this population.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E"]
Explanation
Choice A rationale:
Washing the penis with warm water and mild soap each day is not an appropriate statement regarding circumcision care with a Plastibell device. Keeping the area clean is essential, but soap may irritate the wound, and frequent washing can disrupt the healing process.
Choice B rationale:
Ensuring a loose diaper in the front is not directly related to circumcision care with a Plastibell device. It may be relevant for comfort, but it does not address specific care for the circumcision site.
Choice C rationale:
This is a correct statement indicating understanding of circumcision care with the Plastibell device. The plastic ring is expected to fall off on its own within a week, and this is a normal part of the healing process.
Choice D rationale:
Applying petroleum jelly to the penis during diaper changes is not recommended for circumcision care with a Plastibell device. The petroleum jelly can interfere with wound healing and should be avoided.
Choice E rationale:
This is also a correct statement indicating understanding of circumcision care. If bleeding occurs after the Plastibell has fallen off, it could be a sign of a complication, and the doctor should be notified promptly.
Correct Answer is B
Explanation
The nurse should first report the client's respiratory status to the primary health care.
Choice A rationale:
Reporting the client's laboratory results to the primary health care is important, but in a newborn with respiratory distress and acidosis, addressing the respiratory status takes precedence. The priority is to ensure the newborn's respiratory stability and adequate oxygenation.
Choice B rationale:
Reporting the client's respiratory status to the primary health care is the correct action. A newborn with respiratory distress syndrome and respiratory acidosis requires immediate attention. The primary health care provider needs to be informed promptly to make decisions about further interventions and management.
Choice C rationale:
Reporting the client's brachial pulses to the primary health care is essential, but it is not the priority in this situation. The primary concern is the newborn's respiratory distress and acidosis, which needs to be addressed first.
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