A nurse is assessing a postmature infant. Which of the following findings would the nurse expect? (Select All that Apply.)

Vernix in the folds and creases

Short, soft fingernails

Abundant lanugo

Cracked, peeling skin

Creases covering soles of feet

Positive moro reflex

Answer and Explanation

Correct Answer : D,E,F

A. Vernix in the folds and creases. Vernix caseosa is typically decreased or absent in postmature infants.
B. Short, soft fingernails. Postmature infants usually have long, hard fingernails.
C. Abundant lanugo. Lanugo (fine body hair) is usually less or absent in postmature infants, which is more typical of preterm infants.
D. Cracked, peeling skin. Postmature infants often have dry, peeling skin due to prolonged exposure to amniotic fluid.
E. Creases covering soles of feet. This is a sign of maturity; postmature infants have more developed skin creases on the soles of their feet.
F. Positive moro reflex. This is a normal reflex seen in infants and should be present in a postmature infant.

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Correct Answer is D

Explanation

A. Encourage the client to empty her bladder. This might help if the fundus were not midline, but since it is firm and midline, it’s not necessary.
B. Notify the client's provider. Immediate notification is not required for these findings as they are within the expected range postpartum.
C. Increase the frequency of fundal massage. Frequent fundal massage is not necessary since the fundus is already firm.
D. Document the findings and continue to monitor the client. A firm fundus with moderate bleeding and small clots can be normal in the immediate postpartum period. The nurse should document these findings and continue to monitor.

A. Have you passed any clots? B. Do you have to go to the bathroom? C. When was the last time you changed your pad? D. Are you having any cramping?

Correct Answer is A

Explanation

A. Have you passed any clots? This is important to assess for potential postpartum hemorrhage, which can be indicated by passage of large clots.
B. Do you have to go to the bathroom? This does not directly address the issue of excessive bleeding.
C. When was the last time you changed your pad? This provides information about the amount of bleeding but does not address clotting.
D. Are you having any cramping? Cramping is common postpartum but does not directly assess for hemorrhage.

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A nurse is assessing a postmature infant. Which of the following findings would the nurse expect? (Select All that Apply.)

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Correct Answer is D

Explanation

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Correct Answer is A

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A nurse is assessing a postmature infant. Which of the following findings would the nurse expect? (Select All that Apply.)