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 C

Explanation

A. Umbilical cord compression. This typically results in variable decelerations, not late decelerations.
B. Fetal head compression. This is usually associated with early decelerations.
C. Uteroplacental insufficiency. Late decelerations occur after the peak of contractions and are indicative of insufficient blood flow and oxygen to the fetus, suggesting a problem with the placenta's ability to provide adequate oxygen.
D. Maternal bradycardia. Maternal bradycardia does not cause fetal decelerations.

A. The baseline FHR can be obtained via ultrasound or auscultation B. The baseline FHR can be obtained during contractions C. The baseline FHR is normal between 110-160 bpm D. The baseline FHR is assessed over a 10-minute period

Correct Answer is B

Explanation

A. The baseline FHR can be obtained via ultrasound or auscultation: True. The baseline fetal heart rate can be assessed using ultrasound or auscultation, which are standard methods.
B. The baseline FHR can be obtained during contractions: False. The baseline fetal heart rate should be obtained in the absence of uterine contractions because contractions can temporarily alter the heart rate, making it difficult to determine the true baseline.
C. The baseline FHR is normal between 110-160 bpm: True. This is the accepted normal range for baseline fetal heart rates.
D. The baseline FHR is assessed over a 10-minute period: True. The baseline is typically assessed over a 10-minute window to account for variability and provide an accurate average.

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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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