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A nurse is assessing a newborn who was born at 42 weeks of gestation.
Which of the following findings should the nurse expect?

A.

Copious vernix.

B.

Dry, cracked skin.

C.

Increased subcutaneous fat.

D.

Scant scalp hair.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Copious vernix is typically found on preterm newborns, not those born post-term.

 

Choice B rationale

Dry, cracked skin is a common finding in post-term newborns due to prolonged exposure to amniotic fluid.

 

Choice C rationale

Decreased subcutaneous fat is more likely in preterm newborns, while post-term newborns might lose some fat due to nutrient depletion.

 

Choice D rationale

Scant scalp hair is more common in preterm infants, whereas post-term infants usually have more developed hair. .


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View Related questions

Correct Answer is C

Explanation

Choice A rationale

A maternal blood pressure of 128/88 mm Hg is within normal limits for a pregnant woman. Regular monitoring is necessary, but no immediate follow-up is required unless symptoms

of preeclampsia appear.

Choice B rationale

A fetal heart rate baseline of 115 bpm is within the normal range (110-160 bpm). This does not require immediate follow-up and is a reassuring sign of fetal well-being.

Choice C rationale

A maternal heart rate of 128 bpm is elevated (tachycardia) and may indicate distress, infection, dehydration, or other underlying conditions. This requires immediate follow-up to identify and address the cause.

Choice D rationale

A maternal respiratory rate of 18 breaths per minute is within the normal range (12-20 breaths per minute) and does not require immediate follow-up.

Correct Answer is A

Explanation

Choice A rationale

A boggy and displaced fundus typically indicates bladder distention. Assisting the client to void can help relieve bladder distention, allowing the uterus to contract properly and

reducing the risk of postpartum hemorrhage.

Choice B rationale

Asking the client to rate her pain is important, but it does not address the immediate issue of a boggy, displaced fundus, which suggests bladder distention.

Choice C rationale

Encouraging the client to move to the left lateral position might help with blood flow and comfort but does not resolve the issue of a boggy fundus due to bladder distention.

Choice D rationale

Kegel exercises strengthen pelvic floor muscles but do not address the immediate concern of a boggy, displaced fundus caused by bladder distention.

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