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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

An APGAR score of 5 indicates significant distress and poor adjustment to extrauterine life, which is not consistent with the provided description of the infant's condition.

Choice B rationale

An APGAR score of 6 suggests moderate difficulty with extrauterine adaptation, which is still not entirely consistent with the overall assessment of the infant.

Choice C rationale

An APGAR score of 7 aligns with the described observations of the newborn: pink trunk and head, bluish extremities, active movement, heart rate of 130/min, and a response to

suctioning, which suggest the infant is in reasonably good condition with some minor issues that need monitoring.

Choice D rationale

An APGAR score of 8 would indicate that the newborn is in very good condition with only slight adjustments needed, which does not fully match the infant's description with the noted

issues like a weak cry and bluish extremities.

Correct Answer is B

Explanation

Choice A rationale

Acrocyanosis is a common and typically benign condition in newborns, characterized by bluish discoloration of the hands and feet. It is not an immediate priority.

Choice B rationale

Respiratory distress is the priority assessment for a newborn immediately following a cesarean delivery. Ensuring the newborn has a patent airway and is breathing effectively is crucial for their survival and immediate well-being.

Choice C rationale

Hypothermia is a concern for newborns, but respiratory distress takes precedence as an immediate life-threatening condition.

Choice D rationale

Accidental lacerations can occur during a cesarean delivery, but they are usually not life-threatening and can be addressed after ensuring the newborn's respiratory status is stable. .

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