The nurse is assessing the gestational age of a 1-hour-old newborn. Which physical characteristics does the nurse assess? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply
1. Sole creases
2. Amount of breast tissue
3. Amount of lanugo
4. Reflexes
5. Testicular descent
1,2,3,5
Rationale 1: Sole creases are reliable indicators of gestational age in the first 12 hours of life.
Rationale 2: As gestation progresses, the breast tissue mass and areola enlarge.
Rationale 3: The amount of lanugo is greatest at 28–30 weeks, after which the lanugo disappears.
Rationale 4: Reflexes are neurologic–not physical–characteristics, and are not used to assess gestational age.
Rationale 5: By term, the testes are generally in the lower scrotum, which is pendulous and covered with rugae.
You might also like to view...
During a craniotomy, the patient experienced peripheral damage to cranial nerve VII, resulting in diminished movement of the left side of the face. What nursing action demonstrates best understanding of the effect of this lesion on the patient?
A) Referral for speech therapy and swallowing assessment B) Use of ocular moisturizers C) Teaching about falling and syncope risks D) Referral for evaluation for a hearing aid
The nurse is providing care to clients who are considered vulnerable. What is the ultimate goal of their care?
1. Decreasing risk factors for disease. 2. Educating on healthy living. 3. Providing psychosocial support. 4. Eliminating access barriers.
The adrenal glands are located:
a. In the neck b. Behind the eyes c. Next to the thyroid glands d. On top of each kidney
The nurse is reviewing the functions of the ovaries, uterus, clitoris, and vagina with a group of nursing students. What would be the best response by a nursing student about the function of the ovaries?
A) Produces female gametes or ova and secretes female sex hormones B) Receives the fertilized ovum and provides housing and nourishment for a fetus C) Receives sperm, provides an exit for menstrual flow, and serves as the birth canal D) Small erectile structure that responds to sexual stimulation