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

Cracked, peeling skin.

Positive moro reflex.

Creases covering soles of feet.

Short soft fingernails.

Vernix in the folds and creases.

Answer and Explanation

Correct Answer : C

Choice A rationale

Applying petroleum jelly to the umbilical cord stump is discouraged as it may trap moisture, creating an environment conducive to bacterial growth. Dry cord care is preferred to reduce the risk of infection.

Choice B rationale

Washing the cord daily with soap and water is unnecessary and could lead to irritation or prolonged drying time. The cord stump requires minimal handling to promote natural healing and detachment.

Choice C rationale

Giving sponge baths ensures the cord stump remains dry, which is essential for preventing infection and expediting natural detachment. This method avoids soaking the stump, reducing the risk of maceration or bacterial colonization.

Choice D rationale

Covering the umbilical cord stump with a diaper increases moisture retention, which can delay healing. Proper diaper placement below the stump is recommended to minimize irritation and promote airflow.

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Correct Answer is ["6"]

Explanation

The correct answer is Apgar score of 6.

Step 1 is to evaluate each of the five components of the Apgar score at 1 minute:

Heart rate: 120/min scores 2 points (normal heart rate is ≥100 beats per minute).
Respiratory effort: Slow and weak cry scores 1 point (normal is a strong cry, scoring 2 points).
Muscle tone: Some flexion of extremities scores 1 point (normal is active motion, scoring 2 points).
Reflex irritability: Grimace in response to suctioning scores 1 point (normal is crying or withdrawal, scoring 2 points).
Color: Body pink with blue extremities scores 1 point (normal is completely pink, scoring 2 points).

Step 2 is to sum up the points. (2 + 1 + 1 + 1 + 1) = Apgar score of 6. .

A. Fetal breathing. B. Fetal motion. C. Amniotic fluid volume assessment. D. Fetal neck translucency. E. Fetal gender.

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

Explanation

Choice A rationale

Cracked, peeling skin is typical of postmature infants due to prolonged exposure to amniotic fluid. Reduced vernix caseosa, which normally protects the skin, exacerbates this peeling.

Choice B rationale

A positive Moro reflex is an expected neurologic finding in postmature infants, demonstrating an intact central nervous system. Persistence or absence may indicate neurologic compromise requiring further evaluation.

Choice C rationale

Creases covering the soles of the feet are common in postmature infants due to advanced physical maturity. Increased plantar creasing correlates with gestational age and tissue development.

Choice D rationale

Postmature infants often have long, hardened fingernails rather than short, soft nails. Extended gestation promotes additional growth, distinguishing them from premature or term neonates.

Choice E rationale

Vernix is typically absent or minimal in postmature infants due to its absorption after 40 weeks of gestation. Limited vernix increases the risk of skin desquamation and irritation.

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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

Correct Answer is ["6"]

Explanation

A nurse is caring for a client having a biophysical profile.The client asks what the test is for.What should the nurse include in the response? (Select all that apply.)

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

Explanation

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