A nurse is assisting with the assessment of a newborn who was born at 32 weeks of gestation.

The newborn’s birth weight is 1,100 g. What are the expected findings in this newborn? (Select all that apply.)

Plump face

Dehydration

Long nails

Weak grasp reflex

Presence of lanugo .

Answer and Explanation

Correct Answer : C,D,E

Choice A rationale
A newborn born at 32 weeks of gestation and weighing 1,100 g is considered preterm and is likely to have a thin, fragile appearance rather than a plump face.
Choice B rationale
Dehydration is not a typical finding in a preterm newborn unless there are underlying health issues or complications.
Choice C rationale
Long nails are a common finding in preterm newborns. This is because nail growth begins in the womb and preterm babies have had less time to wear down their nails through movement.
Choice D rationale
A weak grasp reflex is common in preterm newborns. This is due to their immature nervous system.
Choice E rationale
The presence of lanugo, or fine hair, is common in preterm newborns. Lanugo usually begins to disappear around 32 weeks of gestation, so a baby born at this time may still have a significant amount.

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Correct Answer is B

Explanation

Choice A rationale
While reduced fetal oxygen supply can occur with hypertonic contractions and inadequate uterine relaxation, it’s not the primary adverse effect. The main concern is the impact on the progress of labor.
Choice B rationale
This is the correct answer. Inadequate uterine relaxation between hypertonic contractions can delay cervical dilation, slowing the progress of labor.
Choice C rationale
Prolonged labor is not typically associated with hypertonic contractions and inadequate uterine relaxation. In fact, these conditions can lead to a more rapid labor.
Choice D rationale
Increased maternal stress can occur with any labor complication, but it’s not the primary adverse effect of hypertonic contractions and inadequate uterine relaxation.

A. Administer morphine via IV bolus. B. Position the infant in a knee-chest position. C. Perform nasopharyngeal suctioning for a maximum of 5 seconds. D. Request a prescription for a diuretic. E. Administer an additional dose of digoxin. F. Prepare to assist with the insertion of a chest tube.

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

Explanation

Choice A rationale
Administering morphine via IV bolus is not typically a recommended action for an infant diagnosed with Tetralogy of Fallot. While morphine can be used in certain situations to manage pain or anxiety, it is not a specific treatment for the symptoms associated with Tetralogy of Fallot.
Choice B rationale
Positioning the infant in a knee-chest position can be beneficial for infants with Tetralogy of Fallot. This position can help increase blood flow to the lungs, which can improve oxygenation and alleviate symptoms.
Choice C rationale
Performing nasopharyngeal suctioning for a maximum of 5 seconds is not a specific action for an infant diagnosed with Tetralogy of Fallot. While suctioning can be used to clear the airway in certain situations, it does not address the underlying heart defects associated with Tetralogy of Fallot.
Choice D rationale
Requesting a prescription for a diuretic is not typically a recommended action for an infant diagnosed with Tetralogy of Fallot. Diuretics are often used to manage fluid balance in the body, but they do not address the underlying heart defects associated with Tetralogy of Fallot.
Choice E rationale
Administering an additional dose of digoxin can be beneficial for infants with Tetralogy of Fallot. Digoxin is a medication that helps strengthen the heart muscle, enabling it to pump more efficiently. This can help manage symptoms associated with Tetralogy of Fallot.
Choice F rationale
Preparing to assist with the insertion of a chest tube is not a specific action for an infant diagnosed with Tetralogy of Fallot. While a chest tube can be used to manage certain respiratory conditions, it does not address the underlying heart defects associated with Tetralogy of Fallot.

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A nurse is assisting with the assessment of a newborn who was born at 32 weeks of gestation. The newborn’s birth weight is 1,100 g. What are the expected findings in this newborn? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in labor who is experiencing incomplete uterine relaxation between hypertonic contractions. What adverse effect does the nurse recognize as a result of this contraction pattern?

Correct Answer is B

Explanation

A nurse is caring for an infant diagnosed with Tetralogy of Fallot. The infant has been feeding poorly and has difficulty gaining weight. What actions should the nurse plan to take? (Select all that apply.)

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

Explanation

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A nurse is assisting with the assessment of a newborn who was born at 32 weeks of gestation.

The newborn’s birth weight is 1,100 g. What are the expected findings in this newborn? (Select all that apply.)