Which data should alert the nurse that the neonate is postmature?
Presence of lanugo
Short, chubby appearance
Presence of vernix caseosa
Cracked, peeling skin
The Correct Answer is D
Choice A: This is incorrect because lanugo is a fine, downy hair that covers the fetus in utero. It usually disappears by the 36th week of gestation, but it may persist in some preterm infants. Lanugo helps to retain body heat and protect the skin from amniotic fluid. Lanugo is not a sign of postmaturity, but of prematurity or intrauterine growth restriction.
Choice B: This is incorrect because a short, chubby appearance is typical of a term infant, who is born between 37 and 42 weeks of gestation. A term infant has a well-developed subcutaneous fat layer that gives them a rounded shape and smooth skin. A term infant also has a head circumference that is proportional to their body length and weight. A short, chubby appearance is not a sign of postmaturity, but of normal development.
Choice C: This is incorrect because vernix caseosa is a white, cheesy substance that covers the fetus in utero. It usually decreases by the 40th week of gestation, but it may remain in some term infants, especially in the skin folds. Vernix caseosa helps to moisturize and protect the skin from amniotic fluid and infection. Vernix caseosa is not a sign of postmaturity, but of term or near-term gestation.
Choice D: This is the correct answer because cracked, peeling skin is a common sign of postmaturity, which occurs when the infant is born after 42 weeks of gestation. A postmature infant has a loss of subcutaneous fat and water that results in dry, wrinkled, and desquamated skin. A postmature infant also has a large head circumference that is disproportionate to their body length and weight. Cracked, peeling skin indicates prolonged exposure to amniotic fluid and placental insufficiency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A) Report of absent breast pain is incorrect because this is not a finding that indicates that the medication was effective, but rather a finding that indicates that the client does not have mastitis or engorgement. Mastitis is an infection of the breast tissue that causes pain, swelling, redness, and fever. Engorgement is a condition where the breasts become overfilled with milk, causing pain, hardness, and leakage. Both conditions are common in postpartum women who are breastfeeding, but they are not related to methylergonovine or uterine bleeding. Therefore, this response is irrelevant and inaccurate.
Choice B) Increase in lochia is incorrect because this is not a finding that indicates that the medication was effective, but rather a finding that indicates that the medication was ineffective or that the client has a complication. Lochia is the vaginal discharge that consists of blood, mucus, and tissue from the uterus after childbirth. It usually lasts for about 4 to 6 weeks and gradually decreases in amount and color. Methylergonovine is a medication that helps to control uterine bleeding by improving the tone and contractions of the uterus. An increase in lochia may mean that methylergonovine did not work well or that the client has a problem such as retained placenta, infection, or subinvolution. Therefore, this response is opposite and inaccurate.
Choice C) Increase in blood pressure is incorrect because this is not a finding that indicates that the medication was effective, but rather a finding that indicates that the client has a side effect or a risk factor. Blood pressure is the force of blood against the walls of the arteries. It is measured by two numbers: systolic (the pressure when the heart beats) and diastolic (the pressure when the heart rests). The normal range for blood pressure is 120/80 mm Hg or lower. Methylergonovine is a medication that can cause vasoconstriction, which means narrowing of the blood vessels and increasing of the blood pressure. This can lead to complications such as hypertension, stroke, or heart attack. Therefore, this response is adverse and inaccurate.
Choice D) Fundus firm to palpation is correct because this is a finding that indicates that the medication was effective and that the client has a good outcome. The fundus is the upper part of the uterus that can be felt through the abdomen after childbirth. It should be firm, midline, and at or below the level of the navel. A firm fundus means that the uterus has contracted well and stopped bleeding. Methylergonovine is a medication that helps to achieve this by improving the tone and contractions of the uterus. Therefore, this response is positive and accurate.
Correct Answer is A
Explanation
Choice a) This could result in profound bleeding is correct because this is the primary reason why an internal examination should be avoided for a client who has placenta previa. Placenta previa is a condition where the placenta covers part or all of the cervix, preventing normal delivery. An internal examination involves inserting a gloved finger or a speculum into the vagina and cervix to assess their dilation, effacement, position, and station. This can cause trauma to the cervix or the placenta, which can trigger severe hemorrhage and endanger the mother and the fetus. Therefore, this explanation is accurate and appropriate.
Choice b) This could initiate preterm labor is incorrect because this is not the main reason why an internal examination should be avoided for a client who has placenta previa. Placenta previa is a condition where the placenta covers part or all of the cervix, preventing normal delivery. An internal examination may stimulate uterine contractions, which can lead to preterm labor and delivery. However, this is not the most serious or likely complication of an internal examination for a client who has placenta previa, as the bleeding risk is much higher and more urgent. Therefore, this explanation is incomplete and misleading.
Choice c) There is an increased risk of introducing infection is incorrect because this is not a specific reason why an internal examination should be avoided for a client who has placenta previa. Placenta previa is a condition where the placenta covers part or all of the cervix, preventing normal delivery. An internal examination may introduce bacteria or other microorganisms into the vagina or cervix, which can cause infection and inflammation. However, this is a general risk that applies to any pregnant woman who undergoes an internal examination, not just those who have placenta previa. Therefore, this explanation is irrelevant and inaccurate.
Choice d) There is an increased risk of rupture of the membranes is incorrect because this is not a relevant reason why an internal examination should be avoided for a client who has placenta previa. Placenta previa is a condition where the placenta covers part or all of the cervix, preventing normal delivery. An internal examination may cause rupture of the membranes, which are the sacs that contain the amniotic fluid and the fetus. However, this is not a significant or common complication of an internal examination for a client who has placenta previa, as the membranes are usually located above or away from the placenta and cervix. Therefore, this explanation is improbable and inaccurate.
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