A nurse is preparing to assess a newborn who is post-term. Which of the following findings should the nurse expect? (Select all that apply)
Vernix in the folds and creases
Abundant lanugo
Positive Moro reflex
Cracked peeling skin
Short soft fingernails
Correct Answer : A,C,D
Choice A reason:
Vernix in the folds and creases: Vernix caseosa is a white, cheese-like substance that covers the skin of the fetus. In post-term newborns, vernix is typically absent or only present in small amounts in the folds and creases of the skin.
Choice B reason:
Abundant lanugo: Lanugo is fine, soft hair that covers the body of the fetus. It is usually shed before birth, and post-term infants typically have little to no lanugo.
Choice C reason:
Positive Moro reflex: The Moro reflex, or startle reflex, is a normal reflex for an infant when they feel as if they are falling. This reflex is present at birth and usually disappears by 4 months of age.
Choice D reason:
Cracked peeling skin: Post-term infants often have dry, cracked, and peeling skin due to prolonged exposure to amniotic fluid.
Choice E reason:
Short soft fingernails: Post-term infants usually have long fingernails, not short and soft ones.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D"]
Explanation
Choice A reason:
“Small for gestational age” (SGA) refers to babies who are smaller than the typical weight for their gestational age, usually below the 10th percentile. An 8-pound 15-ounce baby born at 35 weeks is not considered SGA because this weight is above the average for that gestational age
Choice B reason:
“Term” refers to babies born between 37 and 42 weeks of gestation. Since the baby in question was born at 35 weeks, they are not considered term.
Choice C reason:
“Preterm” refers to babies born before 37 weeks of gestation. A baby born at 35 weeks falls into this category and is specifically classified as a “late preterm” infant3. Late preterm infants are those born between 34 and 36 weeks of gestation. These babies may require additional medical support compared to full-term infants but generally have better outcomes than those born earlier.
Choice D reason:
“Average for gestational age” (AGA) refers to babies whose weight is within the normal range for their gestational age, typically between the 10th and 90th percentiles. An 8-pound 15-ounce baby born at 35 weeks is considered AGA because this weight is within the expected range for that gestational age.
Choice E reason:
“Post term” refers to babies born after 42 weeks of gestation. Since the baby in question was born at 35 weeks, they are not considered post term.
Correct Answer is B
Explanation
Choice A Reason:
The presence of 3+ protein in the urine is consistent with preeclampsia. Proteinuria is a key diagnostic criterion for preeclampsia, indicating kidney involvement and damage. High levels of protein in the urine are a common finding in patients with preeclampsia.
Choice B Reason:
Deep tendon reflexes of 1+ are inconsistent with preeclampsia. Preeclampsia often causes hyperreflexia, which means increased reflex responses. Typically, patients with preeclampsia exhibit brisk reflexes (3+ or 4+), which can be a sign of central nervous system irritability and an increased risk of seizures.
Choice C Reason:
A blood pressure reading of 148/98 mm Hg is consistent with preeclampsia. Preeclampsia is characterized by high blood pressure, defined as systolic blood pressure of 140 mm Hg or higher, or diastolic blood pressure of 90 mm Hg or higher, measured on two occasions at least four hours apart.
Choice D Reason:
1+ pitting sacral edema is consistent with preeclampsia. Edema, particularly in the lower extremities and sacral area, is a common symptom of preeclampsia due to increased capillary permeability and fluid retention.
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