A nurse is assessing a newborn who was born at 42 weeks of gestation.
Which of the following findings should the nurse expect?
Copious vernix.
Dry, cracked skin.
Increased subcutaneous fat.
Scant scalp hair.
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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Correct Answer is D
Explanation
Choice A rationale
Breast tenderness is considered a presumptive sign of pregnancy, as it can result from hormonal changes, but it is not definitive enough to confirm pregnancy.
Choice B rationale
Fetal heart tones detected by ultrasound are a positive sign of pregnancy. However, it is not a probable sign as it is definitive evidence of an existing pregnancy.
Choice C rationale
Fetal movement, often felt later in pregnancy, is a positive sign. It indicates an existing pregnancy but is not used to initially diagnose pregnancy.
Choice D rationale
A positive urine pregnancy test is a probable sign of pregnancy. It detects the presence of hCG (human chorionic gonadotropin), a hormone produced during pregnancy, and is a widely used indicator of probable pregnancy. .
Correct Answer is C
Explanation
Choice A rationale
Increasing the rate of infusion of IV oxytocin in the presence of abnormal fetal heart rate decelerations is contraindicated. It may exacerbate uterine hyperstimulation, further compromising fetal oxygenation.
Choice B rationale
Decreasing the rate of infusion of the maintenance IV solution will not address the issue of uterine hyperstimulation or abnormal fetal heart rate decelerations. The focus should be on managing oxytocin administration.
Choice C rationale
Discontinuing the infusion of IV oxytocin is appropriate due to uterine tachysystole and associated fetal heart rate decelerations. This helps reduce uterine contractions and allows for fetal recovery, improving oxygenation.
Choice D rationale
Slowing the client's rate of breathing is not related to managing uterine contractions or fetal heart rate decelerations. The intervention should directly address the cause of the decelerations, which is oxytocin-induced hyperstimulation. .