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. Administer parenteral antibiotics. The primary concern with premature rupture of membranes (PROM) is the risk of infection, so administering antibiotics is crucial to prevent infection in both the mother and fetus.
B. Prepare for delivery. Without signs of labor, the focus is on preventing infection and monitoring, not immediate delivery.
C. Provide emotional support. While important, the priority intervention is preventing infection.
D. Assess cervical dilation every 6 hours. Routine cervical checks are not typically necessary unless there are signs of labor or other indications.

A. Limit alcohol and caffeine intake B. Decreasing the intake of dairy products C. Performing regular weight-bearing exercises D. Taking vitamin E and B complex vitamin supplements

Correct Answer is A

Explanation

A. Limit alcohol and caffeine intake. This is important for bone health and overall well-being during menopause, especially since alcohol and caffeine can affect bone density.
B. Decreasing the intake of dairy products. While calcium intake is important, decreasing dairy intake is not a recommended strategy during menopause unless there are specific dietary restrictions or intolerances.
C. Performing regular weight-bearing exercises. This is important for maintaining bone density but may not be the most important measure compared to limiting alcohol and caffeine intake.
D. Taking vitamin E and B complex vitamin supplements. While vitamins are important, they are not as critical as lifestyle measures like limiting alcohol and caffeine.

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

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