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 ["A","B","E","F"]
Explanation
A. Substance use. Parents or caregivers who use substances are more likely to abuse children due to impaired judgment and increased stress levels.
B. Extreme stress. High levels of stress in the family can increase the risk of child abuse as it can lead to frustration and inappropriate coping mechanisms.
C. High socioeconomic background. This is not typically associated with increased risk of child abuse; abuse can occur across all socioeconomic levels, but certain stressors are more prevalent in lower socioeconomic contexts.
D. Strong support system. A strong support system typically acts as a protective factor against child abuse by providing resources and emotional support to caregivers.
E. Prematurity. Premature infants often have increased care needs, which can lead to parental stress and potential abuse.
F. Chronic illness. Children with chronic illnesses may require more care, leading to caregiver stress and higher risk of abuse.
Correct Answer is ["A","B","D","E"]
Explanation
A. Tachypnea. Rapid breathing can indicate respiratory distress associated with heart failure.
B. Wheezes or rales. These are abnormal breath sounds indicating fluid in the lungs, which can occur with heart failure.
C. Bounding pulses. Bounding pulses are not typically associated with heart failure; weak pulses may be present due to poor perfusion.
D. Edematous. Edema can occur due to fluid retention, a sign of heart failure.
E. Difficulty feeding. Poor feeding can result from decreased cardiac output affecting systemic circulation and energy for feeding.
F. Increased comfort laying down. Children with heart failure often prefer sitting upright due to respiratory distress.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.