in the ballard gestational age assessment tool the nurse determines that a 15 month old infant has a gestational age of 42 weeks based on this finding
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1. In the Ballard Gestational Age Assessment Tool, the nurse determines that a 15-month-old infant has a gestational age of 42 weeks. Based on this finding, which intervention is most important for the nurse to implement?

Correct answer: B

Rationale: Late preterm infants, such as those with a gestational age of 42 weeks, are at higher risk for hypoglycemia due to immature metabolic regulation. Monitoring capillary blood glucose is crucial to detect and manage hypoglycemia promptly. Providing blow-by oxygen (Choice A) is not indicated for an infant at risk for hypoglycemia. Drawing arterial blood gases (Choice C) is not the primary intervention for assessing hypoglycemia. Applying a pulse oximeter to the foot (Choice D) is not directly related to monitoring blood glucose levels in this context.

2. The embryo and fetus develop within a protective _______ in the uterus.

Correct answer: A

Rationale: The correct answer is A, the amniotic sac. The amniotic sac is a fluid-filled structure that surrounds and protects the developing embryo and fetus in the uterus. It provides a cushion against external pressure, allows for movement and growth, and helps maintain a stable environment for the developing fetus. Choices B, C, and D are incorrect. The umbilical cord connects the fetus to the placenta and serves as a conduit for nutrients and waste; the neural tube is a structure that forms the central nervous system in early embryonic development; and the embryonic disk is a structure that forms during gastrulation, one of the early stages of embryonic development.

3. When do mothers usually feel the first fetal movements during pregnancy?

Correct answer: A

Rationale: Mothers usually feel the first fetal movements, known as 'quickening,' around the 18th to 20th week of pregnancy. Feeling fetal movements during the first month is unlikely and uncommon. Therefore, option B is incorrect. Options C and D are also incorrect as mothers typically do feel fetal movements during pregnancy, just not during the first month.

4. On the first postpartum day, the nurse examines the breasts of a new mother. Which condition is the nurse most likely to find?

Correct answer: D

Rationale: On the first postpartum day, the nurse is most likely to find the breasts filling and secreting colostrum. Colostrum secretion is common as the body prepares for breastfeeding in the initial days after delivery. Choice A is incorrect as breasts are not typically very tender immediately postpartum. Choice B is incorrect as an immediate let-down response is more related to lactation rather than the first postpartum day. Choice C is incorrect as the breasts typically undergo changes, such as filling with colostrum, after delivery.

5. Which of the following statements is a characteristic of supermales?

Correct answer: A

Rationale: The correct characteristic of supermales, individuals with an XYY chromosome pattern, is that they are somewhat taller than average. Choice B is incorrect as supermales do not exhibit minimal facial hair growth compared to normal males. Choice C is incorrect as gynecomastia, the development of male breasts, is not a characteristic of supermales. Choice D is also incorrect as impotence is not a typical characteristic associated with supermales.

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