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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Related Questions
Correct Answer is B
Explanation
Choice A rationale
The deltoid muscle is not typically used for intramuscular injections in infants due to its small size.
Choice B rationale
The vastus lateralis muscle is one of the preferred sites for intramuscular injections in infants, including the vitamin K injection. This muscle is large enough to absorb the medication, and injections here carry less risk of hitting a nerve or blood vessel.
Choice C rationale
The ventrogluteal muscle is not typically used for intramuscular injections in infants. This site is often used in older children and adults.
Choice D rationale
The dorsogluteal site is not recommended for intramuscular injections due to the risk of damaging the sciatic nerve.
Correct Answer is A
Explanation
Choice A rationale
A displaced fundus from the midline in a postpartum client can indicate a full bladder, which can interfere with uterine contraction and lead to excessive bleeding. This is a serious
condition that requires immediate attention to prevent further complications such as postpartum hemorrhage.
Choice B rationale
A fundal height below the umbilicus is a normal finding in a postpartum client. The uterus normally decreases in size after delivery, and the fundus is typically located at or below the level of the umbilicus within 24 hours postpartum.
Choice C rationale
Increased urine output is a normal physiological response after delivery. During pregnancy, there is an increase in blood volume that leads to increased fluid in the body. After delivery, the body eliminates this extra fluid through increased urine output.
Choice D rationale
A decreased urge to void can be a normal finding in the immediate postpartum period due to decreased bladder sensitivity from the trauma of childbirth or epidural anesthesia. However, it’s important for the nurse to monitor this because urinary retention can lead to bladder distention and uterine atony, increasing the risk of postpartum hemorrhage.
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