The nurse is assessing a new admission to the newborn nursery. Which physical findings suggest the infant was preterm? Standard Text: Select all that apply
1. The ear pinna quickly returns to original position after being bent manually.
2. The infant's resting position is tightly flexed.
3. Labia widely separated with clitoris prominent.
4. Breast area barely perceptible with flat areola, no bud.
5. Sole creases do not extend the length of the foot.
3,4,5
Rationale 1: This finding is associated with fetal maturity.
Rationale 2: This finding is associated with fetal maturity. A preterm infant will rest with arms and legs extended.
Rationale 3: In the mature infant, the labia covers the perineal area, including the clitoris.
Rationale 4: This is an indication of immaturity associated with the preterm infant.
Rationale 5: This is an indication of a preterm infant.
Global Rationale:
You might also like to view...
The homecare nurse is seeing a patient at 6 weeks postpartum. Which statement by the patient indicates the need for immediate intervention?
1. "The baby sleeps 7 hours each night now." 2. "My flow is red, and I need to wear a pad." 3. "My breasts no longer leak between feedings." 4. "I started back on the pill 2 weeks ago."
According to Freudian psychodynamic theory, the attachment of a girl to her father produces anxiety, which must be resolved and controlled. Which name is used for this attachment?
a. Electra c. Oedipus b. Cleopatra d. Olympia
In planning care for a client with an acute stroke resulting in right-side hemiplegia, which positioning should the nurse use to maintain optimal functioning?
A. supine with trochanter rolls to the hips B. left lateral, supine, brief periods on the right side, and prone C. sim's position alternated with right lateral position q2 hours D. mid-fowler's with knees supported
The nurse obtains a prescription to apply restraints to a patient who is agitated, aggressive, and has threatened two staff members. Which action should the nurse take regarding the use of the restraints?
1. Assess the patient every 6 hours. 2. Ensure that the order is written as "PRN confusion." 3. Remind the healthcare provider to assess the patient every other day. 4. Instruct the patient on the use of the restraints.