Which of the following observations should be recorded as part of a newborn gestational age assessment?
Anterior fontanel soft and level.
Plantar creases cover 3 of the sole.
Acrocyanosis of hands and feet.
Vernix caseosa in inguinal creases
The Correct Answer is B
Choice A rationale
While the anterior fontanel being soft and level is an important observation in a newborn, it is not typically used as part of a gestational age assessment.
Choice B rationale
The presence of plantar creases covering 3 of the sole is a typical finding in a full-term newborn and is used as part of a gestational age assessment.
Choice C rationale
Acrocyanosis, or bluish discoloration of the hands and feet, is a common finding in newborns, especially shortly after birth. However, it is not typically used as part of a gestational age assessment.
Choice D rationale
Vernix caseosa in the inguinal creases can be a sign of a preterm newborn, as vernix caseosa is typically present in larger amounts in preterm newborns. However, it is not typically used as part of a gestational age assessment.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
When breastfeeding, it is recommended that the mother places her nipple and some of the areola into the baby’s mouth. This allows the baby to have a good latch, which is important for effective breastfeeding.
Choice B rationale
While it is important for the baby to take a good portion of the breast into their mouth, suggesting to include some breast tissue beyond the areola might be too much for a newborn’s small mouth.
Choice C rationale
This statement is not entirely accurate. While a newborn’s mouth is small, they should take as much of the nipple and areola into their mouth as possible to ensure effective breastfeeding.
Choice D rationale
While babies have certain instincts, they and their mothers often need guidance and practice to achieve a good latch and effective breastfeeding.
Correct Answer is A
Explanation
Choice A rationale
The priority action by the nurse following an amniotomy is to assess the fetal heart rate. This is because changes in the fetal heart rate can indicate fetal distress, which could be caused by cord compression or other complications related to the amniotomy.
Choice B rationale
While assessing the odor of the amniotic fluid is important to identify possible infections, it is not the priority action following an amniotomy.
Choice C rationale
Providing clean, dry underpads is part of standard care following an amniotomy, but it is not the priority action.
Choice D rationale
Monitoring the client’s temperature is important to identify possible infection, but it is not the priority action immediately following an amniotomy.
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