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 ["A","B","D","E"]

Explanation

A. Tachypnea. Rapid breathing can indicate respiratory distress associated with heart failure.
B. Wheezes or rales. These are abnormal breath sounds indicating fluid in the lungs, which can occur with heart failure.
C. Bounding pulses. Bounding pulses are not typically associated with heart failure; weak pulses may be present due to poor perfusion.
D. Edematous. Edema can occur due to fluid retention, a sign of heart failure.
E. Difficulty feeding. Poor feeding can result from decreased cardiac output affecting systemic circulation and energy for feeding.
F. Increased comfort laying down. Children with heart failure often prefer sitting upright due to respiratory distress.

A. I perform range of motion exercises every 4 hours to help prevent contractures B. I make sure that I use toys and activities that are appropriate for my child's chronological age C. I have utensils with large, padded handles to make it easier for my child to feed himself D. I play games with my child every day to keep them as independent as possible E. I give my child carbidopa so that he will stop drooling

Correct Answer is ["A","C","D"]

Explanation

A. I perform a range of motion exercises every 4 hours to help prevent contractures. This helps prevent the tightening of muscles and joints, reducing the risk of contractures common in spastic cerebral palsy.
B. I make sure that I use toys and activities that are appropriate for my child's chronological age. While important, this does not specifically address the care needs related to spastic cerebral palsy.
C. I have utensils with large, padded handles to make it easier for my child to feed himself. Adaptive utensils promote independence in self-care activities.
D. I play games with my child every day to keep them as independent as possible. Engaging in activities that promote independence and social interaction is beneficial for children with cerebral palsy.
E. I give my child carbidopa so that he will stop drooling. Medications like carbidopa are not typically used to manage drooling associated with cerebral palsy and are not a primary care measure.

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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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Naxlex Comprehensive Predictor Exams

Which assessment findings would alert the nurse to an infant or child in heart failure? (Select All that Apply.)

Correct Answer is ["A","B","D","E"]

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Which statements made by the parent indicate that appropriate care is being provided to a 4-year-old who has spastic type cerebral palsy? (Select All that Apply.)

Correct Answer is ["A","C","D"]

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