The nurse is caring for a newborn born at 30 weeks' gestation.
Which assessment finding should the nurse anticipate?

Plantar creases over the entire sole.

Flexion of all four extremities.

Abundance of subcutaneous fat deposits.

Lanugo covering most of the body.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Plantar creases appear over the entire sole closer to term gestation (37-40 weeks). At 30 weeks, these creases are confined to the anterior sole, reflecting the immature integumentary system. Absence of full creases correlates with preterm gestational age, assisting in clinical age assessment of neonates.

Choice B rationale

Preterm neonates at 30 weeks exhibit hypotonia, with minimal extremity flexion. Flexion develops progressively as the central nervous system matures. Hypotonia reflects developmental immaturity and is a distinguishing feature in preterm infants compared to term neonates.

Choice C rationale

Subcutaneous fat deposition is limited in preterm neonates, contributing to their thin, translucent skin and increased risk of thermoregulation issues. Fat accumulation occurs primarily in the third trimester, and its absence is a hallmark of premature neonates, requiring external temperature support.

Choice D rationale

Lanugo, a fine hair covering the body, is prominent in neonates born at 30 weeks. It serves as an adaptive mechanism for thermoregulation in utero. Lanugo decreases closer to term as subcutaneous fat increases. Its presence confirms preterm status and aids in gestational age assessment.

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Correct Answer is A

Explanation

Choice A rationale

Weighing an infant's diaper for output is a task suitable for unlicensed assistive personnel (UAP) because it involves data collection rather than clinical judgment or critical thinking. The results can be recorded and reported to the nurse for further assessment and interpretation.

Choice B rationale

Assessing a post-operative dressing requires clinical judgment to identify signs of infection, dehiscence, or other complications. This task is within the scope of a licensed nurse and should not be delegated to UAP to ensure patient safety.

Choice C rationale

Calculating the Morse Fall Scale involves understanding and interpreting risk factors, which requires critical thinking and clinical judgment. It is inappropriate for delegation to UAP, as they are not trained to analyze or interpret clinical data.

Choice D rationale

Performing an assessment of a child's developmental milestones requires knowledge of growth and development patterns, as well as clinical judgment to interpret findings. This task is outside the scope of UAP and must be performed by a licensed nurse.

A. Perform a sterile vaginal exam. B. Establish IV access. C. Obtain fetal heart rate. D. Assess the client's vital signs.

Correct Answer is C

Explanation

Choice A rationale

Performing a sterile vaginal exam assesses cervical dilation and effacement, which is essential for labor progression. However, it poses an infection risk after membrane rupture and should follow fetal heart rate evaluation to ensure fetal well-being.

Choice B rationale

Establishing IV access is important for administering fluids or medications. Still, it is not immediately necessary without first assessing the fetal and maternal condition, which dictates further intervention needs.

Choice C rationale

Obtaining the fetal heart rate is the priority after membrane rupture and bloody show. It evaluates fetal oxygenation and well-being, especially with frequent contractions. Tachycardia or decelerations may indicate distress, necessitating immediate intervention.

Choice D rationale

Assessing maternal vital signs provides insight into hemodynamic status but is secondary to immediate fetal monitoring. Fetal heart rate assessment directs urgent management, especially in high-risk scenarios like ruptured membranes and bloody show. .

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The nurse is caring for a newborn born at 30 weeks' gestation.Which assessment finding should the nurse anticipate?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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The nurse is caring for a newborn born at 30 weeks' gestation.
Which assessment finding should the nurse anticipate?