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.
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Related Questions
Correct Answer is B
Explanation
Choice A Reason:
While assessing bowel sounds is important for overall patient care, it is not the priority when administering magnesium sulfate. Magnesium sulfate is primarily used to prevent seizures in preeclampsia and to manage preterm labor. Its side effects can include respiratory depression, making respiratory rate the most critical assessment.
Choice B Reason:
Respiratory rate is the priority assessment when administering magnesium sulfate. Magnesium sulfate can cause respiratory depression, which can be life-threatening. Monitoring the respiratory rate helps ensure that the client is not experiencing adverse effects from the medication. The normal respiratory rate for adults is 12-20 breaths per minute.
Choice C Reason:
Temperature monitoring is important for detecting infections and other conditions, but it is not the priority in this context. Magnesium sulfate does not typically affect body temperature, so this assessment is less critical compared to respiratory rate.
Choice D Reason:
Fetal heart rate (FHR) monitoring is crucial for assessing fetal well-being, especially in clients with preeclampsia or preterm labor. However, the immediate priority when administering magnesium sulfate is to monitor the mother’s respiratory rate to prevent respiratory depression.
Correct Answer is A
Explanation
Choice A Reason:
The primary reason for performing an ultrasound before an amniocentesis is to identify the location of the placenta and fetus. This ensures that the needle used for the procedure can be safely inserted into the amniotic sac without harming the fetus or placenta12. The ultrasound helps guide the healthcare provider to a safe location for the needle insertion, minimizing risks associated with the procedure.
Choice B Reason:
While an ultrasound can be useful for estimating fetal age, this is not the primary reason for performing it before an amniocentesis. The main goal is to ensure the safety of the procedure by accurately locating the fetus and placenta.
Choice C Reason:
An ultrasound is not primarily a screening tool for spina bifida. Although it can help detect certain congenital anomalies, the main purpose of the ultrasound before an amniocentesis is to guide the needle insertion safely.
Choice D Reason:
Determining if there is more than one fetus can be an incidental finding during an ultrasound, but it is not the primary reason for performing the ultrasound before an amniocentesis. The main objective is to ensure the safe placement of the needle by identifying the exact location of the fetus and placenta.
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