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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 A

Explanation

Choice A rationale

It is common for children who are hospitalized to regress temporarily in their behavior, including toilet training. Stress, unfamiliar environments, and illness can contribute to this regression. Assuring the parents that the child’s skills will return when they feel better helps alleviate their concerns.

Choice B rationale

Asking why it bothers the parent that their child has wet the bed may come across as insensitive or confrontational. It does not provide support or reassurance to the parent.

Choice C rationale

Telling the parent not to worry about the child wetting the bed because the child did not seem upset dismisses the parent’s feelings and does not address the underlying issue of the child’s regression.

Choice D rationale

Sharing personal experiences and saying it doesn’t bother the nurse may seem empathetic but does not provide the professional reassurance and support the parents need. It shifts the focus to the nurse rather than addressing the parents' concerns.

Correct Answer is C

Explanation

Choice A rationale

While knowing the adverse effects of medication is important, understanding why the child is taking the medication is crucial for ensuring adherence and proper administration.

Choice B rationale

Stopping medication when the child feels better can lead to incomplete treatment and antibiotic resistance. This is incorrect advice to give to parents.

Choice C rationale

Knowing the reason for taking the medication ensures that parents understand its importance, which promotes adherence to the prescribed regimen.

Choice D rationale

Using a kitchen spoon to administer medication can lead to inaccurate dosing. A proper measuring device, such as an oral syringe, should be used.

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