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

Answer and Explanation

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.

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Correct Answer is ["D","E","F"]

Explanation

A. Vernix in the folds and creases. Vernix caseosa is typically decreased or absent in postmature infants.
B. Short, soft fingernails. Postmature infants usually have long, hard fingernails.
C. Abundant lanugo. Lanugo (fine body hair) is usually less or absent in postmature infants, which is more typical of preterm infants.
D. Cracked, peeling skin. Postmature infants often have dry, peeling skin due to prolonged exposure to amniotic fluid.
E. Creases covering soles of feet. This is a sign of maturity; postmature infants have more developed skin creases on the soles of their feet.
F. Positive moro reflex. This is a normal reflex seen in infants and should be present in a postmature infant.

A. Sunken fontanels B. Retinal hemorrhage C. Laceration to forearm. D. Large bruises on the body

Correct Answer is B

Explanation

A. Sunken fontanels: Sunken fontanels are typically associated with dehydration rather than abusive head trauma.
B. Retinal haemorrhage: Retinal haemorrhages are a key indicator of abusive head trauma, such as shaken baby syndrome. They are caused by the shearing forces of rapid acceleration and deceleration.
C. Laceration to forearm: While concerning, a laceration to the forearm is not specific to abusive head trauma and could result from various types of trauma.
D. Large bruises on the body: While large bruises might indicate physical abuse, they are not specific to head trauma and do not point as directly to abusive head trauma as retinal haemorrhages do.

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The nurse is caring for a newborn born at 31 weeks' gestation. Which assessment finding should the nurse anticipate?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a postmature infant. Which of the following findings would the nurse expect? (Select All that Apply.)

Correct Answer is ["D","E","F"]

Explanation

A 2-month-old is brought into the emergency room. Which factor leads the RN to suspect abusive head trauma?

Correct Answer is B

Explanation

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