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The nurse is using the New Ballard Score to assess the gestational age of a newborn delivered 4 hours ago. The infant's gestational age is 33 weeks based on early ultrasound and last menstrual period. The nurse expects the infant to exhibit which of the following?
- A. Full sole creases, nails extending beyond the fingertips, scarf sign showing the elbow beyond the midline
- B. Testes located in the upper scrotum, rugae covering the scrotum, vernix covering the entire body
- C. Ear cartilage folded over, lanugo present over much of the body, slow recoil time
- D. 1 cm breast bud, peeling skin and veins not visible, rapid recoil of legs and arms to extension
Correct Answer: C
Rationale: The correct answer is C. Ear cartilage folded over, lanugo present over much of the body, and slow recoil time are all characteristics of a preterm infant. A is incorrect because full sole creases, nails extending beyond the fingertips, and scarf sign showing the elbow beyond the midline are features of a term infant. B is incorrect as testes located in the upper scrotum, rugae covering the scrotum, and vernix covering the entire body are also indicative of a term infant. D is incorrect because a 1 cm breast bud, peeling skin and veins not visible, and rapid recoil of legs and arms to extension are characteristics seen in a more mature infant, not a preterm newborn.
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Warning signs that indicate dehydration include all EXCEPT:
- A. Poor skin turgor
- B. Increased urine output
- C. Tachycardia
- D. Eager to drink
Correct Answer: B
Rationale: The correct answer is B. Increased urine output is not a warning sign of dehydration; it typically decreases with dehydration. Dehydration often presents with poor skin turgor, tachycardia, and an increased sensation of thirst (eager to drink) as the body tries to compensate for fluid loss. Choices A, C, and D are all correct warning signs of dehydration. Poor skin turgor is a result of decreased skin elasticity due to fluid loss. Tachycardia, an elevated heart rate, can be a compensatory mechanism to maintain cardiac output in dehydration. Feeling eager to drink is a common symptom of dehydration as the body attempts to restore fluid balance.
In the treatment of an infected hematoma, which of the following is NOT recommended?
- A. Incision and drainage
- B. Systemic antibiotics
- C. A and B
- D. Vitamin E
Correct Answer: D
Rationale: Vitamin E is not a standard treatment for infected hematomas. The primary interventions for infected hematomas typically involve incision and drainage to remove infected fluid and debris, along with the administration of systemic antibiotics to combat the infection. Vitamin E does not play a significant role in the treatment of infected hematomas and is therefore not recommended as a primary treatment option. Choice A (Incision and drainage) and Choice B (Systemic antibiotics) are recommended treatments for infected hematomas as they help in removing infected fluid and combating the infection, respectively. Therefore, the correct answer is D, Vitamin E.
The provider is educating the parents of a newborn about circumcision care. Which of the following instructions should be included?
- A. Cleanse the penis with each diaper change using alcohol wipes.
- B. Avoid using petroleum jelly on the circumcision site.
- C. Report any yellowish exudate around the head of the penis.
- D. Use warm water to clean the penis gently during diaper changes.
Correct Answer: D
Rationale: The correct instruction for circumcision care is to use warm water to gently clean the penis during diaper changes. Alcohol wipes should be avoided as they can cause irritation. Yellowish exudate around the head of the penis is a normal part of the healing process and does not require reporting unless accompanied by other concerning symptoms. Avoiding petroleum jelly on the circumcision site is important to prevent trapping moisture and bacteria, which can lead to infection.
The student nurse has performed a gestational age assessment of an infant and finds the infant to be at 32 weeks. On which set of characteristics is the nurse basing this assessment?
- A. Lanugo mostly gone, little vernix remaining on the body
- B. Prominent clitoris, enlarging labia minora, patent anus
- C. Full areola, 5 to 10 mm nipple bud, pinkish-brown areola
- D. Skin opaque, cracking at wrists and ankles, no visible vessels
Correct Answer: B
Rationale: The correct answer is B. At 30 to 32 weeks' gestation, the clitoris is prominent, and the labia minora are enlarging. The labia majora are small and widely separated. As gestational age increases, the labia majora increase in size. At 36 to 40 weeks, they almost cover the clitoris. At 40 weeks and beyond, the labia majora cover the labia minora and clitoris. Choices A, C, and D do not align with the characteristic features seen at 32 weeks of gestation, making them incorrect.
The healthcare provider is teaching a new mother how to care for her newborn's umbilical cord. Which instruction should be included?
- A. Keep the cord dry and exposed to air
- B. Clean the cord with alcohol at every diaper change
- C. Cover the cord with a sterile dressing
- D. Submerge the cord in water during baths
Correct Answer: A
Rationale: Keeping the umbilical cord dry and exposed to air is the correct instruction because it promotes faster healing. Moisture can delay the healing process and increase the risk of infection. Cleaning the cord with alcohol at every diaper change or covering it with a sterile dressing can actually impede the healing process by preventing airflow. Submerging the cord in water during baths is not recommended as it can introduce moisture and increase the risk of infection.