A nurse is completing a newborn gestational age assessment. Which of the following findings should be recorded as part of this assessment on the newborn?
Plantar creases cover 2/3 of sole
Acrocyanosis of hands and feet
Anterior fontanel soft and level
Vernix caseosa in inguinal creases
The Correct Answer is A
- A: Plantar creases covering 2/3 of the sole is indicative of a more mature newborn, which is a significant finding in assessing gestational age.
- B: Acrocyanosis of hands and feet is a common finding in the first few days after birth and is not specifically related to gestational age.
- C: The condition of the anterior fontanel being soft and level is a normal finding and does not contribute to the assessment of gestational age.
- D: The presence of vernix caseosa in inguinal creases can be seen in both preterm and full-term newborns, thus it is not a specific indicator of gestational age.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The fundus palpable to the right of midline suggests that the bladder is distended and pushing the uterus to the right, displacing it from its expected midline position.
B. Less than 2.5 cm of rubra lochia on the perineal pad is a normal amount of lochia for 2 hours postpartum and does not necessarily indicate bladder distention.
C. Client report of frequent uterine contractions may indicate uterine involution but does not directly assess bladder distention.
D. Client report of increased thirst may indicate dehydration but does not directly assess bladder distention.
Correct Answer is C
Explanation
A. Sleeping for long stretches between feedings may indicate inadequate feeding rather than sufficient breast milk intake.
B. Having a wake cycle of 30 to 60 minutes after each feeding is not a reliable indicator of sufficient breast milk intake.
C. Wetting 6 to 8 diapers per day indicates that the baby is adequately hydrated and receiving enough breast milk.
D. Burping after each feeding is important for gas relief but does not directly indicate sufficient breast milk intake.
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