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Which observation is expected when the nurse is assessing the gestational age of a neonate born at term?

A.

No creases on the plantar surface of the foot.

B.

Abundant lanugo covering most of the body.

C.

Flexed position at rest.

D.

Pinna of the ear that remains folded.

Answer and Explanation

The Correct Answer is C

Choice A rationale

The absence of creases on the plantar surface is typical of a preterm infant, not a term infant. Term infants usually have some creases.

 

Choice B rationale

Abundant lanugo is more common in preterm infants, while term infants may have some but not extensive lanugo.

 

Choice C rationale

A flexed position at rest is expected in a term neonate, as it indicates good muscle tone and neuromuscular development.

 

Choice D rationale

The pinna of the ear remaining folded is more indicative of a preterm infant, as term infants typically have fully formed and firmer ear cartilage.


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Correct Answer is C

Explanation

Choice A rationale

Encouraging play exercises in the evening can lead to overstimulation, which can make it harder for the toddler to fall asleep. Physical activity should generally be done earlier in the day to help with sleep later on.

Choice B rationale

Turning off the room light can create a dark environment conducive to sleep, but it doesn’t address the need for a calming routine, which is essential for young children’s sleep. Some children also feel safer with a nightlight.

Choice C rationale

Providing bedtime rituals can help signal to the toddler that it is time to wind down and sleep. Consistent rituals, such as reading a story or singing a lullaby, provide a sense of security and comfort.

Choice D rationale

Explaining the source of the toddler’s fears may be beyond the cognitive ability of a toddler and does not directly promote sleep. It’s better to provide comfort and reassurance through routine.

Correct Answer is B

Explanation

Choice A rationale

Constructing a model airplane may require smaller parts and more intricate work, not ideal for a 4-year-old child.

Choice B rationale

Putting together a large-piece puzzle is suitable for fine motor skills development and can be done while in isolation.

Choice C rationale

Playing in the hallway would expose the child to other areas and people, defeating the purpose of airborne precautions.

Choice D rationale

Watching a video game in the playroom is not feasible as it would require leaving the isolation area.

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