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

Lanugo covering most of the body

Flexion of all four (4) extremities

Plantar creases over the entire sole

Abundance of subcutaneous fat deposits

Answer and Explanation

The Correct Answer is A

A. Lanugo (fine hair) covers most of the body in preterm infants. It helps with heat regulation but decreases as the fetus matures.

B. Incorrect → Flexion of all extremities is seen in term infants. Preterm infants often have hypotonia (decreased muscle tone).

C. Incorrect → Plantar creases are absent or few in preterm infants. Term infants have creases covering the entire sole.

D. Incorrect → Preterm infants have less subcutaneous fat, making them more prone to temperature instability.

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Correct Answer is ["B","C","F"]

Explanation

A. Decreased urine output → Not a direct sign of PDA; it may indicate other conditions such as heart failure or hypoperfusion.

B. Bounding peripheral pulses → PDA causes increased systemic blood flow due to left-to-right shunting, leading to strong, bounding pulses.

C. Wide pulse pressure → PDA increases systolic pressure while lowering diastolic pressure, widening the pulse pressure.

D. Bradycardia → PDA is more likely to cause tachycardia due to increased cardiac workload.

E. Cyanosis of the extremities → PDA primarily causes left-to-right shunting, which does not typically result in cyanosis unless Eisenmenger syndrome (reversal to right-to-left shunting) develops.

A. A parent who is experiencing high levels of stress B. The child was born prematurely C. A parent with a history of experiencing abuse during their own childhood D. The child's performance in school is above average E. The parent's have a strong support system F. The child has developmental disabilities

Correct Answer is ["A","B","C","F"]

Explanation

A. High parental stress → Stress, financial struggles, and lack of support increase the risk of abuse.

B. Prematurity → Premature infants may have health complications or require extra care, increasing stress on caregivers.

C. Parental history of abuse → A history of being abused as a child is a known risk factor for becoming an abusive parent.

D. Above-average school performance → This is not a risk factor.

E. Strong parental support system → A strong support system reduces the risk of abuse.

F. Developmental disabilities → Children with disabilities may be more vulnerable to neglect or abuse.

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

Nursing Test Bank

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