Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a postmature infant. Which of the following findings would the nurse expect? (Select All that Apply.)
A. Vernix in the folds and creases
Vernix in the folds and creases. Vernix caseosa is typically decreased or absent in postmature infants.
B. Short, soft fingernails
Short, soft fingernails. Postmature infants usually have long, hard fingernails.
C. Abundant lanugo
Abundant lanugo. Lanugo (fine body hair) is usually less or absent in postmature infants, which is more typical of preterm infants.
D. Cracked, peeling skin
Cracked, peeling skin. Postmature infants often have dry, peeling skin due to prolonged exposure to amniotic fluid.
E. Creases covering soles of feet
Creases covering soles of feet. This is a sign of maturity; postmature infants have more developed skin creases on the soles of their feet.
F. Positive moro reflex
Positive moro reflex. This is a normal reflex seen in infants and should be present in a postmature infant.
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Full Explanation
A. Vernix in the folds and creases. Vernix caseosa is typically decreased or absent in postmature infants.
B. Short, soft fingernails. Postmature infants usually have long, hard fingernails.
C. Abundant lanugo. Lanugo (fine body hair) is usually less or absent in postmature infants, which is more typical of preterm infants.
D. Cracked, peeling skin. Postmature infants often have dry, peeling skin due to prolonged exposure to amniotic fluid.
E. Creases covering soles of feet. This is a sign of maturity; postmature infants have more developed skin creases on the soles of their feet.
F. Positive moro reflex. This is a normal reflex seen in infants and should be present in a postmature infant.
Similar Questions
Which newborn assessment finding would require the nurse to report to the health care provider?
A. The newborn who has cyanotic hands and feet.
The newborn who has cyanotic hands and feetCyanosis, a bluish or purplish discoloration of the skin, in the hands and feet of a newborn can indicate a breathing problem or poor circulation. This requires prompt evaluation by a healthcare provider.
B. The newborns whose head turns toward the cheek being stroked
The newborn whose head turns toward the cheek being stroked. This describes the rooting reflex, which is normal.
C. The newborn whose toes curl when the lateral heel is stroked
The newborn whose toes curl when the lateral heel is stroked. This describes the Babinski reflex, which is also normal for infants.
D. The newborn who extends the arms when hearing a loud noise
The newborn who extends the arms when hearing a loud noise. This describes the Moro reflex, which is normal and should not require reporting.
Full Explanation
A. The newborn who has cyanotic hands and feetCyanosis, a bluish or purplish discoloration of the skin, in the hands and feet of a newborn can indicate a breathing problem or poor circulation. This requires prompt evaluation by a healthcare provider.
B. The newborn whose head turns toward the cheek being stroked. This describes the rooting reflex, which is normal.
C. The newborn whose toes curl when the lateral heel is stroked. This describes the Babinski reflex, which is also normal for infants.
D. The newborn who extends the arms when hearing a loud noise. This describes the Moro reflex, which is normal and should not require reporting.
A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?
A. Encourage the client to empty her bladder.
Encourage the client to empty her bladder. This might help if the fundus were not midline, but since it is firm and midline, it’s not necessary.
B. Notify the client's provider.
Notify the client's provider. Immediate notification is not required for these findings as they are within the expected range postpartum.
C. Increase the frequency of fundal massage.
Increase the frequency of fundal massage. Frequent fundal massage is not necessary since the fundus is already firm.
D. Document the findings and continue to monitor the client.
Document the findings and continue to monitor the client. A firm fundus with moderate bleeding and small clots can be normal in the immediate postpartum period. The nurse should document these findings and continue to monitor.
Full Explanation
A. Encourage the client to empty her bladder. This might help if the fundus were not midline, but since it is firm and midline, it’s not necessary.
B. Notify the client's provider. Immediate notification is not required for these findings as they are within the expected range postpartum.
C. Increase the frequency of fundal massage. Frequent fundal massage is not necessary since the fundus is already firm.
D. Document the findings and continue to monitor the client. A firm fundus with moderate bleeding and small clots can be normal in the immediate postpartum period. The nurse should document these findings and continue to monitor.
A nurse is assessing the fundus of a postpartum patient one day after delivery and notes that the fundus is soft and spongy. Which is the first nursing intervention to preform?
A. Administer Oxytocin IV per MD orders
Administer Oxytocin IV per MD orders. This may be done after attempting fundal massage to help firm the uterus, but massage is the first step.
B. Notify the healthcare provider
Notify the healthcare provider. This would be done if the fundus does not respond to massage or if excessive bleeding continues, but not before attempting to firm the fundus.
C. Document the fundal height and consistency
Document the fundal height and consistency. Documentation is important but should occur after addressing the immediate issue of a soft fundus to prevent hemorrhage.
D. Massage the fundus until it firms
Massage the fundus until it firms. The immediate action should be to massage the uterus to promote contraction and reduce bleeding. A soft, spongy uterus indicates uterine atony, which can lead to hemorrhage.
Full Explanation
A. Administer Oxytocin IV per MD orders. This may be done after attempting fundal massage to help firm the uterus, but massage is the first step.
B. Notify the healthcare provider. This would be done if the fundus does not respond to massage or if excessive bleeding continues, but not before attempting to firm the fundus.
C. Document the fundal height and consistency. Documentation is important but should occur after addressing the immediate issue of a soft fundus to prevent hemorrhage.
D. Massage the fundus until it firms. The immediate action should be to massage the uterus to promote contraction and reduce bleeding. A soft, spongy uterus indicates uterine atony, which can lead to hemorrhage.