The nurse is caring for a newborn born at 31 weeks' gestation. Which assessment finding should the nurse anticipate?

Sole creases on heels

Ruddy skin color

Flexion of all four (4) extremities

Scant amount of vernix caseosa

Answer and Explanation

The Correct Answer is D

A. Sole creases on heels. Sole creases are a sign of maturity and are usually present in full-term infants, not preterm.
B. Ruddy skin color. This is more common in infants with polycythemia or those who are small for gestational age, not specifically linked to prematurity.
C. Flexion of all four extremities. Premature infants typically have less muscle tone and may exhibit less flexion, often appearing more limp or having extended extremities.
D. Scant amount of vernix caseosa. Premature infants typically have more vernix caseosa, which protects their delicate skin in utero. The amount decreases closer to full term, but at 31 weeks, there may still be a moderate amount.

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Correct Answer is A

Explanation

A. Call the child abuse hotline. A spiral fracture, especially in a non-ambulatory infant, is highly suspicious for non-accidental trauma (child abuse). Reporting suspected abuse is mandatory to protect the child from further harm.
B. Educate the mother on safety. While important for prevention, addressing potential abuse takes precedence.
C. Inform the mother to call the nurse for all diaper changes. This does not address the immediate concern of suspected child abuse.
D. Complete the Morse Fall Scale. This is irrelevant in the context of suspected child abuse.

A. Wash the cord daily with mild soap and water. B. Cover the cord with the diaper. C. Apply petroleum jelly to the cord stump. D. Give a sponge bath until the cord stump falls off.

Correct Answer is D

Explanation

A. Wash the cord daily with mild soap and water. Incorrect because keeping the area dry is crucial; soap can irritate the area.
B. Cover the cord with the diaper. Incorrect because it may trap moisture and cause irritation or infection.
C. Apply petroleum jelly to the cord stump. Incorrect because this may keep the area too moist and prevent it from drying and falling off naturally.
D. Give a sponge bath until the cord stump falls off. This prevents the cord from getting wet, which can increase the risk of infection and delay drying and detachment.

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The nurse is caring for a newborn born at 31 weeks' gestation. Which assessment finding should the nurse anticipate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A newborn is admitted with a diagnosis of a spiral fracture of the right femur. The mother states the child received the injury when the baby fell off the changing table. Which would be the priority nursing intervention?

Correct Answer is A

Explanation

A nurse is teaching a newborn's parent to care for the umbilical cord stump. Which of the following instructions should the nurse include?

Correct Answer is D

Explanation

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