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","D","E"]

Explanation

A. Incentive spirometer 10 times every hour – Not practical or necessary for an infant.

B. Maintain a thermoneutral environment – Prevents stress and oxygen demand increase.

C. Encourage periods of bonding – Important for emotional well-being and development.

D. Accurately measure intake and output – Ensures proper fluid balance.

E. Provide for several periods of uninterrupted rest – Reduces metabolic demand and supports recovery.

A. Increase the frequency of fundal massage. B. Document the findings and continue to monitor the client. C. Encourage the client to empty her bladder. D. Notify the provider immediately.

Correct Answer is B

Explanation

A. Increase the frequency of fundal massage – Unnecessary if the fundus is firm.

B. A firm fundus with normal lochia rubra and small clots is expected. No immediate intervention is required.

C. Encourage the client to empty her bladder – Bladder distention can cause postpartum hemorrhage, but this scenario does not indicate bladder issues.

D. Notify the provider immediately – Not required unless excessive bleeding or signs of hemorrhage occur.

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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

The nurse is caring for an infant following the surgical repair of an atrial septal defect. Which nursing interventions are appropriate for this infant? (Select All that Apply.)

Correct Answer is ["B","C","D","E"]

Explanation

A nurse is assessing a client 1 hour after delivery and notices a large amount of lochia rubra along with several small clots on the perineal pad. The client's fundus is firm and located at the umbilical level, in the midline. What action should the nurse take next?

Correct Answer is B

Explanation

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