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 A
Explanation
Choice a) I will be certain to empty the litter boxes regularly is incorrect because this is a risky behavior for a pregnant woman who wants to prevent toxoplasmosis. Toxoplasmosis is an infection caused by a parasite called Toxoplasma gondii, which can be found in the feces of cats and other animals. If a pregnant woman gets infected with toxoplasmosis, she can pass it to her unborn baby, which can cause serious problems such as miscarriage, stillbirth, or birth defects. Therefore, a pregnant woman should avoid contact with cat litter and let someone else handle the litter boxes, or wear gloves and wash her hands thoroughly if she has to do it herself.
Choice b) I have to wash all of my fruits and vegetables is correct because this is a good practice for a pregnant woman who wants to prevent toxoplasmosis. Toxoplasmosis can also be transmitted through contaminated soil or water, which can adhere to fruits and vegetables. Therefore, a pregnant woman should wash all of her fruits and vegetables before eating them, and peel or cook them if possible, to remove any traces of the parasite.
Choice c) I won't eat raw eggs is correct because this is another good practice for a pregnant woman who wants to prevent toxoplasmosis. Toxoplasmosis can also be acquired through eating undercooked or raw meat or eggs that contain the parasite. Therefore, a pregnant woman should avoid eating raw eggs or any foods that contain them, such as mayonnaise, mousse, or homemade ice cream, and cook all of her meat and eggs thoroughly until they are no longer pink or runny.
Choice d) I need to be cautious when cooking meat is correct because this is also an important practice for a pregnant woman who wants to prevent toxoplasmosis. Toxoplasmosis can also be spread through handling raw meat that contains the parasite. Therefore, a pregnant woman should be careful when cooking meat and use separate utensils and cutting boards for raw and cooked meat, wash her hands and surfaces after touching raw meat, and avoid tasting raw meat while cooking it.

Correct Answer is C
Explanation
Choice A) Newborns are abdominal breathers is incorrect because this is not a reason why the respiratory rate should be counted for a complete minute, but rather a characteristic of how newborns breathe. Abdominal breathing means that the diaphragm and the abdominal muscles are the main muscles used for breathing, rather than the chest muscles. Newborns are abdominal breathers because their chest wall is more compliant and less stable than adults, and their intercostal muscles are not fully developed. Abdominal breathing does not affect the accuracy or duration of measuring the respiratory rate, as long as the abdomen is visible and palpable. Therefore, this response is irrelevant and inaccurate.
Choice B) Activity will increase the respiratory rate is incorrect because this is not a reason why the respiratory rate should be counted for a complete minute, but rather a factor that can influence the respiratory rate. Activity means any physical or mental exertion that requires more oxygen and energy from the body. Activity can increase the respiratory rate, as well as the heart rate and blood pressure, to meet the increased oxygen demand and carbon dioxide removal. However, activity does not affect the accuracy or duration of measuring the respiratory rate, as long as the newborn is calm and resting during the measurement. Therefore, this response is irrelevant and inaccurate.
Choice C) The rate and rhythm of breath are irregular in newborns is correct because this is a reason why the respiratory rate should be counted for a complete minute. The rate and rhythm of breath refer to how fast and how regularly one breathes. Newborns have an irregular rate and rhythm of breath, which means that they breathe at different speeds and intervals, sometimes pausing for a few seconds between breaths. This is normal and harmless for newborns, as long as they do not stop breathing for more than 20 seconds or show signs of distress. However, it can make it difficult to measure the respiratory rate accurately, as counting for a shorter period may not reflect the true average rate. Therefore, counting for a complete minute can ensure a more reliable measurement. Therefore, this response is clear and accurate.
Choice D) Newborns do not expand their lungs fully with each respiration is incorrect because this is not a reason why the respiratory rate should be counted for a complete minute, but rather a feature of how newborns breathe.
Lung expansion means how much air one inhales and exhales with each breath. Newborns do not expand their lungs fully with each respiration, because they have smaller lung volumes and capacities than adults, and they breathe more shallowly and rapidly. However, lung expansion does not affect the accuracy or duration of measuring the respiratory rate, as long as the chest or abdomen movement is visible and palpable. Therefore, this response is irrelevant and inaccurate.

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