The nurse is caring for a newborn born at 31 weeks' gestation. Which assessment finding should the nurse anticipate?
Sole creases on heels
Ruddy skin color
Flexion of all four (4) extremities
Scant amount of vernix caseosa
The Correct Answer is D
A. Sole creases on heels. Sole creases are a sign of maturity and are usually present in full-term infants, not preterm.
B. Ruddy skin color. This is more common in infants with polycythemia or those who are small for gestational age, not specifically linked to prematurity.
C. Flexion of all four extremities. Premature infants typically have less muscle tone and may exhibit less flexion, often appearing more limp or having extended extremities.
D. Scant amount of vernix caseosa. Premature infants typically have more vernix caseosa, which protects their delicate skin in utero. The amount decreases closer to full term, but at 31 weeks, there may still be a moderate amount.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
A. Chronic fatigue. While chronic fatigue can occur in muscular dystrophy due to muscle weakness, it is not a direct side effect of corticosteroids.
B. Weight gain: Corticosteroids commonly cause weight gain due to increased appetite and fluid retention.
C. Mood changes: Mood swings and changes in behaviour are well-documented side effects of corticosteroid use.
D. Weight loss. Corticosteroids typically cause weight gain rather than weight loss.
E. Osteoporosis: Long-term use of corticosteroids can lead to decreased bone density and osteoporosis, making bone fractures more likely.
Correct Answer is ["6"]
Explanation
Heart rate (110/min): 2 points
Respiratory effort (slow, weak cry): 1 point
Muscle tone (some flexion of extremities): 1 point
Reflex irritability (grimace): 1 point
Color (body pink, blue extremities): 1 point
APGAR-6
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