A nurse is collecting data from a newborn immediately after delivery by a client who was at 42 weeks of gestation. Which of the following findings should the nurse expect?
Scant scalp hair
Copious vernix
Increased subcutaneous fat
Dry, cracked skin
The Correct Answer is D
Choice A reason:
Scant scalp hair is not an expected finding for a newborn who is post-term. Scant scalp hair is more common in preterm infants who have not developed fully.
Choice B reason:
Copious vernix is not an expected finding for a newborn who is post-term. Vernix is a white, cheesy substance that covers the skin of the fetus and protects it from the amniotic fluid. Vernix is usually abundant in preterm infants and decreases as gestation progresses.
Choice C reason:
Increased subcutaneous fat is not an expected finding for a newborn who is post-term. Increased subcutaneous fat is a sign of adequate nutrition and growth, which is more likely in term infants. Post-term infants may have reduced subcutaneous fat due to placental insufficiency and decreased nutrient supply.
Choice D reason:
Dry, cracked skin is an expected finding for a newborn who is post-term. Dry, cracked skin is a result of prolonged exposure to the amniotic fluid, which causes dehydration and desquamation of the skin. Post-term infants may also have meconium staining on their skin due to fetal distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","F","H"]
Explanation
Choice A reason
Blood pressure is not a priority finding for a newborn with neonatal abstinence syndrome (NAS). Blood pressure is usually normal or slightly elevated in NAS, and it is not a reliable indicator of the severity of withdrawal symptoms.
Choice B reason
Gastrointestinal disturbances are a common and serious finding for a newborn with NAS. Vomiting and diarrhea can lead to dehydration, electrolyte imbalance, and poor weight gain. Projectile vomiting can also increase the risk of aspiration. This finding requires immediate follow-up and intervention.
Choice C reason
Skin color is not a priority finding for a newborn with NAS. Acrocyanosis (bluish color of the hands and feet) is a normal finding in newborns and does not indicate hypoxia or poor circulation. It usually resolves within the first few days of life.
Choice D reason
NAS score is not a priority finding for a newborn with NAS. NAS score is a tool used to assess the severity of withdrawal symptoms and the need for pharmacological treatment. It is based on a set of clinical signs and symptoms that are scored at regular intervals. However, it is not a substitute for clinical judgment and individualized care. The NAS score alone does not determine the urgency of follow-up.
Choice E reason
Temperature is not a priority finding for a newborn with NAS. Temperature may be slightly elevated or normal in NAS, and it is not a specific sign of infection or withdrawal. Temperature regulation is important for newborns, but it is not an immediate concern in this case.
Choice F reason
Oxygen saturation is a priority finding for a newborn with NAS. Tachypnea (rapid breathing) and retractions (inward movement of the chest wall) are signs of respiratory distress, which can compromise oxygen delivery to the tissues and organs. Hypoxia (low oxygen level) can cause brain damage, organ failure, and death if not corrected promptly. This finding requires immediate follow-up and intervention.
Choice G reason
Central nervous system disturbances are a priority finding for a newborn with NAS. Increased muscle tone, tremors, high-pitched cry, and seizures are signs of neurological dysfunction,which can indicate brain injury, bleeding, or infection. Seizures can also worsen hypoxia and metabolic acidosis. This finding requires immediate follow-up and intervention.
Choice H reason
Respiratory rate is not a priority finding for a newborn with NAS. Respiratory rate may be increased or normal in NAS, and it is not a specific sign of respiratory distress or infection. Respiratory rate should be monitored along with other vital signs.
Correct Answer is ["B","C","D","F","G"]
Explanation
Choice A:
Temperature is not a finding that the nurse should report to the provider. The normal range for temperature in newborns is 36.5 to 37 degrees Celsius axillary. The question does not provide the temperature of the newborn, but it does not indicate any signs of hypothermia or hyperthermia.
Choice B:
Respiratory findings are findings that the nurse should report to the provider. The newborn has mild grunting, nasal flaring, and intermittent retractions, which are signs of respiratory distress. These could indicate a problem with lung development, infection, or congenital heart disease.
Choice C:
Serum glucose is a finding that the nurse should report to the provider. The normal range for blood glucose in newborns is above 40 mg/dL. The question does not provide the serum glucose level of the newborn, but it could be low due to factors such as prematurity, maternal diabetes, or sepsis.
Choice D:
Hematocrit is a finding that the nurse should report to the provider. The normal range for hematocrit in newborns is 42% to 65%. The question does not provide the hematocrit level of the newborn, but it could be high due to polycythemia or low due to anemia or hemorrhage.
Choice E:
White blood cell count is not a finding that the nurse should report to the provider. The normal range for white blood cell count in newborns is 9,000 to 30,000/mm3. The question does not provide the white blood cell count of the newborn, but it does not indicate any signs of infection or inflammation.
Choice F:
Hemoglobin is a finding that the nurse should report to the provider. The normal range for hemoglobin in newborns is 14 to 24 g/dL. The question does not provide the hemoglobin level of the newborn, but it could be high due to polycythemia or low due to anemia or hemorrhage.
Choice G:
Heart rate is a finding that the nurse should report to the provider. The normal range for heart rate in newborns is 85 to 190 beats per minute when awake. The question does not provide the heart rate of the newborn, but it could be high due to stress, pain, fever, or hypoxia, or low due to bradycardia or cardiac arrest.
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