Which observation is expected when the nurse is assessing the gestational age of a neonate born at term?
No creases on the plantar surface of the foot.
Abundant lanugo covering most of the body.
Flexed position at rest.
Pinna of the ear that remains folded.
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 D
Explanation
Choice A rationale
Examining the tympanic membrane at the beginning may cause distress to the child and make the rest of the exam difficult.
Choice B rationale
Before auscultating the chest and abdomen, the child needs to be calm and cooperative, which might not be the case if their ear is examined first.
Choice C rationale
Examining the tympanic membrane before the head and neck could lead to increased anxiety and uncooperativeness in the child during the rest of the exam.
Choice D rationale
Examining the tympanic membrane at the end allows for a more accurate and complete examination without causing the child to become distressed early in the process.
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.