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":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"C"}}

Explanation

1st Trimester (Conception-13 weeks)

Fetus has a heartbeat: The fetal heartbeat can typically be detected around 6 weeks gestation using ultrasound, marking the beginning of cardiac development in the first trimester.

2nd Trimester (14-26 weeks)

Gender can be determined: Gender determination through ultrasound is generally possible around the 18-20 week mark in the second trimester when fetal genitalia are more distinguishable.

3rd Trimester (27-40 weeks)

Surfactant production: Surfactant production by the fetal lungs begins in the third trimester, usually around 24-28 weeks, but continues to increase throughout the remainder of pregnancy.
Sucking occurs: Fetal sucking movements start to develop around the 28th week and become more coordinated as the third trimester progresses.
Fetal respiratory movements begin: Fetal respiratory movements, where the fetus practices breathing by moving the diaphragm, begin in the third trimester to prepare for life outside the womb.
Increase in body fat: The fetus begins to accumulate more body fat in the third trimester, which helps with thermoregulation and provides energy reserves for birth and early postnatal life.

Finding	1st Trimester Conception-13 weeks	2nd Trimester 14-26 weeks	3rd Trimester 27-40 weeks

Gender can be determined	☐	☒	☐
Surfactant production	☐	☐	☒
Sucking occurs	☐	☐	☒
Fetus has a heartbeat	☒	☐
Fetal respiratory movements begin	☐	☐	☒
Increase in body fat	☐	☐	☐

A. Sunken fontanels B. Retinal hemorrhage C. Laceration to forearm. D. Large bruises on the body

Correct Answer is B

Explanation

A. Sunken fontanels: Sunken fontanels are typically associated with dehydration rather than abusive head trauma.
B. Retinal haemorrhage: Retinal haemorrhages are a key indicator of abusive head trauma, such as shaken baby syndrome. They are caused by the shearing forces of rapid acceleration and deceleration.
C. Laceration to forearm: While concerning, a laceration to the forearm is not specific to abusive head trauma and could result from various types of trauma.
D. Large bruises on the body: While large bruises might indicate physical abuse, they are not specific to head trauma and do not point as directly to abusive head trauma as retinal haemorrhages do.

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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

Identify the trimester when each fetal development finding occurs. Note: Each category must have at least 1 response option selected.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"C"}}

Explanation

A 2-month-old is brought into the emergency room. Which factor leads the RN to suspect abusive head trauma?

Correct Answer is B

Explanation

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