Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Which of the following observations should be recorded as part of a newborn gestational age assessment?
A. Anterior fontanel soft and level.
While the anterior fontanel being soft and level is an important observation in a newborn, it is not typically used as part of a gestational age assessment.
B. Plantar creases cover 3 of the sole.
The presence of plantar creases covering 3 of the sole is a typical finding in a full-term newborn and is used as part of a gestational age assessment.
C. Acrocyanosis of hands and feet.
Acrocyanosis, or bluish discoloration of the hands and feet, is a common finding in newborns, especially shortly after birth. However, it is not typically used as part of a gestational age assessment.
D. Vernix caseosa in inguinal creases
Vernix caseosa in the inguinal creases can be a sign of a preterm newborn, as vernix caseosa is typically present in larger amounts in preterm newborns. However, it is not typically used as part of a gestational age assessment.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Nur 232 Maternity Final Proctored Exam Sp24. Take the full exam now
Full Explanation
Choice A rationale
While the anterior fontanel being soft and level is an important observation in a newborn, it is not typically used as part of a gestational age assessment.
Choice B rationale
The presence of plantar creases covering 3 of the sole is a typical finding in a full-term newborn and is used as part of a gestational age assessment.
Choice C rationale
Acrocyanosis, or bluish discoloration of the hands and feet, is a common finding in newborns, especially shortly after birth. However, it is not typically used as part of a gestational age assessment.
Choice D rationale
Vernix caseosa in the inguinal creases can be a sign of a preterm newborn, as vernix caseosa is typically present in larger amounts in preterm newborns. However, it is not typically used as part of a gestational age assessment.
Similar Questions
What Apgar score should a nurse document for a newborn with a pink trunk and head, bluish hands and feet, flexed extremities 5 min after delivery, a weak and slow cry, a heart rate of 130/min, and cries in response to suctioning?
A. 7
An Apgar score of 7 is considered fairly low and would typically be associated with a newborn who has more significant health concerns.
B. 8
An Apgar score of 8 is considered to be within the normal range. This score would be consistent with a newborn who has a pink trunk and head, bluish hands and feet, flexed extremities, a weak and slow cry, a heart rate of 130/min, and cries in response to suctioning.
C. 9
An Apgar score of 9 is considered to be within the normal range. However, given the newborn’s weak and slow cry, an Apgar score of 9 would be less likely.
D. 10
An Apgar score of 10 is very unusual, as almost all newborns lose 1 point for blue hands and feet, which is normal for after birth.
Full Explanation
Choice A rationale
An Apgar score of 7 is considered fairly low and would typically be associated with a newborn who has more significant health concerns.
Choice B rationale
An Apgar score of 8 is considered to be within the normal range. This score would be consistent with a newborn who has a pink trunk and head, bluish hands and feet, flexed extremities, a weak and slow cry, a heart rate of 130/min, and cries in response to suctioning.
Choice C rationale
An Apgar score of 9 is considered to be within the normal range. However, given the newborn’s weak and slow cry, an Apgar score of 9 would be less likely.
Choice D rationale
An Apgar score of 10 is very unusual, as almost all newborns lose 1 point for blue hands and feet, which is normal for after birth.
What is the estimated date of birth (EDB) for a client who is pregnant and whose last menstrual period began on July 27? (State the date in MMDD.
For example, July 27 is 0727)
A. 0427
To calculate the estimated date of birth (EDB) using the first day of the last menstrual period (LMP), you can use Naegele’s Rule. This rule adds 280 days (or 40 weeks) to the first day of the LMP. Given the LMP of July 27 (0727): Add 1 year: July 27, 2023 becomes July 27, 2024. Add 7 days: July 27, 2024 becomes August 3, 2024. Subtract 3 months: August 3, 2024 becomes May 3, 2024. So, the estimated date of birth (EDB) is May 3, 2024 (0503).
B. 0503
To calculate the estimated date of birth (EDB) using the first day of the last menstrual period (LMP), you can use Naegele’s Rule. This rule adds 280 days (or 40 weeks) to the first day of the LMP. Given the LMP of July 27 (0727): Add 1 year: July 27, 2023 becomes July 27, 2024. Add 7 days: July 27, 2024 becomes August 3, 2024. Subtract 3 months: August 3, 2024 becomes May 3, 2024. So, the estimated date of birth (EDB) is May 3, 2024 (0503).
C. 0603
To calculate the estimated date of birth (EDB) using the first day of the last menstrual period (LMP), you can use Naegele’s Rule. This rule adds 280 days (or 40 weeks) to the first day of the LMP. Given the LMP of July 27 (0727): Add 1 year: July 27, 2023 becomes July 27, 2024. Add 7 days: July 27, 2024 becomes August 3, 2024. Subtract 3 months: August 3, 2024 becomes May 3, 2024. So, the estimated date of birth (EDB) is May 3, 2024 (0503).
D. 0527
To calculate the estimated date of birth (EDB) using the first day of the last menstrual period (LMP), you can use Naegele’s Rule. This rule adds 280 days (or 40 weeks) to the first day of the LMP. Given the LMP of July 27 (0727): Add 1 year: July 27, 2023 becomes July 27, 2024. Add 7 days: July 27, 2024 becomes August 3, 2024. Subtract 3 months: August 3, 2024 becomes May 3, 2024. So, the estimated date of birth (EDB) is May 3, 2024 (0503).
Full Explanation
To calculate the estimated date of birth (EDB) using the first day of the last menstrual period (LMP), you can use Naegele’s Rule. This rule adds 280 days (or 40 weeks) to the first day of the LMP.
Given the LMP of July 27 (0727):
- Add 1 year: July 27, 2023 becomes July 27, 2024.
- Add 7 days: July 27, 2024 becomes August 3, 2024.
- Subtract 3 months: August 3, 2024 becomes May 3, 2024.
So, the estimated date of birth (EDB) is May 3, 2024 (0503).
Which of the following findings should alert a nurse assessing a client who is 8 hr postpartum and multiparous?
A. Fundus three fingerbreadths above the umbilicus.
A fundus that is three fingerbreadths above the umbilicus 8 hours postpartum is a sign of urinary retention, which can displace the uterus and inhibit uterine contraction, leading to postpartum hemorrhage.
B. Moderate lochia rubra.
Moderate lochia rubra, or bloody discharge, is normal within the first few days after childbirth.
C. Blood pressure 130/84 mm Hg.
A blood pressure of 130/84 mm Hg is within the normal range for a postpartum woman.
D. Moderate swelling of the labia.
Moderate swelling of the labia can be a normal finding after a vaginal birth.
Full Explanation
Choice A rationale
A fundus that is three fingerbreadths above the umbilicus 8 hours postpartum is a sign of urinary retention, which can displace the uterus and inhibit uterine contraction, leading to postpartum hemorrhage.
Choice B rationale
Moderate lochia rubra, or bloody discharge, is normal within the first few days after childbirth.
Choice C rationale
A blood pressure of 130/84 mm Hg is within the normal range for a postpartum woman.
Choice D rationale
Moderate swelling of the labia can be a normal finding after a vaginal birth.