The nurse reviews the neonate's medical record and sees the baby ...

[CORALGRILL2014]

The nurse reviews the neonate's medical record and sees the baby is at 38 weeks' gestation. Which of the following findings would make the nurse question the accuracy of this gestation?
 
  1. Infant sleeps with extremities flexed.
  2. Square window of 20 degrees
  3. Elbow moves past midline when assessing scarf sign.
  4. Breast tissue measures 0.7 cm.

Question 2

The nurse determines that the client with venous stasis ulcers understood dietary teaching when the client says:
 
  1. I have increased my carbohydrate intake.
  2. I have reduced my sugar intake.
  3. I have increased my protein intake.
  4. I have decreased my fat intake.

[AISCAMPING]

Answer to Question 1

3
Rationale: When assessing scarf sign, the term infant's elbow should not reach the midline, where the term infant has more flexibility. The other findings would be appropriate with a term infant.

Answer to Question 2

3
Rationale: Increased protein intake is important to replace protein lost through the drainage from the ulcers. In addition, the client needs extra vitamin A, vitamin C, and zinc for wound healing.

[CORALGRILL2014]

Excellent

[kswal303]

TYSM