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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
A. Maintain a thermoneutral environment: Helps prevent temperature fluctuations that can stress the heart post-surgery.
B. Accurately measure all intake and output: Ensures fluid balance is carefully monitored to prevent fluid overload or dehydration.
C. Provide for several periods of uninterrupted rest: Reduces metabolic demand, aiding in recovery and healing.
D. Incentive spirometer 10 times every hour: Inappropriate for infants following cardiac surgery, as they are unable to effectively use an incentive spirometer.
E. Encourage periods of bonding: Supports emotional well-being and aids in the infant's overall recovery and development.
Correct Answer is B
Explanation
A. Hypoplastic heart syndrome: Characterized by underdevelopment of the left side of the heart, not mixing of blood.
B. Atrioventricular canal defect: An atrioventricular canal defect allows oxygenated and deoxygenated blood to mix due to the presence of a common atrioventricular valve and defects in the atrial and ventricular septa. This defect results in a mixture of oxygenated and deoxygenated blood, which can cause varying levels of oxygenation in the blood delivered to the body.
C. Tetralogy of Fallot: Involves a ventricular septal defect leading to right-to-left shunting, but not a direct mixing of oxygenated and deoxygenated blood.
D. Coarctation of the aorta: Involves narrowing of the aorta, not mixing of oxygenated and deoxygenated blood.
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