assessing a newborn

Which assessment finding is priority for the nurse to address during an assessment of a one-week-old neonate?

Mucus in the nasal passages Newborns are obligatory nose breathers and, therefore, have significant distress when their nasal passages are obstructed. Pupillary reflex is poor at birth and improves at 5 months of age. Deciduous tooth eruption takes place between the ages of 6 and 24 months. The tonsils and adenoids are small in relation to body size and hard to see at birth.

A mother brings her 10-month-old infant to the health care clinic for a routine checkup. Which gross motor developmental task should the nurse expect the infant to be able to have achieved?

Pulling up to a standing position is a gross motor skill (at 9 months). Pinching a raisin and transferring blocks between hands are fine motor skills. Vocalization is a cognitive and language skill.

The mother of a newborn has struggled to effectively breastfeed her daughter. The mother has received instruction from a lactation specialist on proper breastfeeding techniques, but the baby will not latch on. She has decided to bottle feed the baby at least for now. Also, when assessing the infant's musculoskeletal system, the nurse found unequal gluteal folds and limited hip abduction. Which of the following should be the priority nursing conclusion?

The priority conclusion is that the infant is at risk for complications related to hip displacement, as the findings of unequal gluteal folds and limited hip abduction indicate. The problem related to breastfeeding does not appear to be an issue of knowledge deficit, as the mother has received proper instruction. Also, risk for ineffective breastfeeding would be an inaccurate diagnosis, as ineffective breastfeeding has already occurred. Because the baby has switched to bottle feeding, however, and because there are no other adverse indications related to the child's weight gain or nutritional status, there is no failure to thrive or risk of complications thereof.

A mother brings her 2-month-old infant to the health care clinic because she has noticed a bulge at the umbilicus that seems to get bigger when the baby cries. That nurse recognizes this as what type of finding?

Umbilical hernia SUBMIT ANSWER

The Moro reflex is

a response to sudden stimulation or an abrupt change in position.

The nurse notes that a sleeping newborn's heart rate is 102 bpm. What action should the nurse take first?

document A pulse rate of 100 bpm when the infant is sleeping is considered normal and should be documented. There is no need to apply oxygen, notify the health care provider, or increase the temperature in the incubator.

When performing an assessment of a 2-month-old infant, the nurse turns the baby's head to the side while the infant is supine. The arm and leg extend on the side to which the face is pointed. The contralateral arm and leg flex, forming the classic fencing position. What is the name of this reflex?

tonic neck reflex A newborn's heart rate ranges from 120 to 160 beats per minute until about 6 months of age. A heart rate less than 100 beats per minute is abnormal, and the nurse needs to further assess the newborn. Normal findings include the newborn crying with flexed extremities, displaying active movement, and having pink skin tone.

A new mother tells the nurse that the newborn has a small yellow lesion on the hard palate of the mouth and is worried about the baby's ability to suck properly. What should the nurse tell the mother about this finding?

"This is common and will disappear within the first few weeks." This finding is common in newborns and is called an Epstein pearl. It is found on the hard palate and gums and presents as a small, yellow-white retention cyst that disappears within the first few weeks of life. Sucking tubercles are common in infants on the upper lip but do not occur from improper sucking. This is not an infection, thus no culture is needed. A cleft palate usually occurs together with a cleft lip. A cleft is a fissure, opening, or gap. It is the nonfusion of the body's natural structures that form before birth.

A newborn appears to be in respiratory distress with a respiratory rate of 70 breaths/min, nasal flaring, and intercostal retractions. The newborn has a temperature of 37.2°C (98.9°F;) and a pulse rate of 190 beats/min. What is the normal range for a newborn's heart rate?

120-160 beats/min

While assessing a young infant's musculoskeletal system, the nurse anticipates that the anterior curve in the cervical region will be developed by

3-4 months By 3 to 4 months, the anterior curve in the cervical region develops from the infant raising its head when prone.

The nurse prepares to assess a newborn's apical heart rate. Where should the nurse place the stethoscope for this assessment?

4th intercostal space, left of the midclavicular line

Upon delivery the newborn is crying; moving; has a heart rate of 146; respiratory rate is slow and irregular; and is cyanotic. What Apgar score would the nurse assign to this newborn?

7 The newborn is crying (2); moving (2); has a heart rate of 146 (2); respiratory rate is slow; and irregular (1); and cyanotic (0) for an Apgar score of 7.

A newborn is being assessed at 1 minute after birth. A score that indicates the newborn is adapting well to the extrauterine environment is in what range?

7-10 The Apgar score is one of the first newborn assessments the nurse makes. It is not used to guide resuscitation efforts but gives important clues about how well the newborn is adapting to life outside the womb. The newborn receives a score of 0 to 2 in each of 5 areas for a possible total score of 10. The score is calculated at 1 min and again at 5 min of life. Score of 7 to 10 indicates a vigorous newborn adapting well to the extrauterine environment. This makes the other options incorrect.

A new mother wants to give her baby honey. The nurse tells her that it is potentially dangerous to do this. Why is this practice potentially dangerous?

Honey is a known reservoir for the botulism bacterium

A mother brings her 3-month-old infant to the health care clinic because she has noticed that her child has developed a sunken abdomen with prominent rib cage. That nurse recognizes the underlying case of this condition is which of the following?

Malnutrition and dehydration

A nurse auscultates the bowel sounds of a 1-month-old. Which of the following findings should warrant further assessment by the nurse?

Marked peristaltic waves almost always indicate a pathologic process such as pyloric stenosis. Normal bowel sounds occur every 10 to 30 seconds. They sound like clicks, gurgles, or growls.

A nurse assesses a newborn and finds a white, cheesy substance on the infant's skin, especially within the folds of the skin. How should the nurse document this finding?

Vernix caseosa

How should a nurse test visual acuity in an infant of 6 weeks of age?

Visual acuity is difficult to test in the infant but is best examined by observing the infant's ability to fix on and follow objects. By 6 to 8 weeks of age, an infant should be able to follow a moving object with the eyes. At 4 weeks of age, an infant can only fixate on an object. Shining a light does not test visual acuity but pupillary response to light. Looking for the light reflex in the eyes is the Hirschberg test which tests for symmetry of the pupils.

A nurse assesses a newborn of African American descent and observes a bluish-pigmented area on the sacrum. The nurse recognizes this as what type of skin variation?

slate gray nevus A bluish coloration of the skin on the sacral area is called a slate gray nevus and is common in infants of Asian, African American, Native American, and Mexican American descent. (Note: slate gray nevi were previously known as Mongolian spots.) Erythema toxicum consists of tiny bumps that are firm, yellowish, or white, and surrounded by a ring of redness. The rash usually appears on the baby's face, chest, arms, and legs. Telangiectatic nevi are flat, red birthmarks often called port wine stains. Trauma from delivery can be seen anywhere and manifest as any type of abnormality.

Which action by the nurse demonstrates the correct technique of assessing for arm recoil?

Flex the elbows up bilaterally

When assessing a child with respiratory distress, it is important to ask further questions. What is the priority question that the nurse needs to ask?

Has the infant been exposed to anyone with a communicable illness?

The nurse assesses the skin of a 2-week-old infant. For which finding should the nurse notify the health care provider?

Hyperpigmented macules are considered Café au lait spots. If more than 6 are present, it may indicate neurofibromatosis and should be reported to the health care provider. A port-wine stain, telangiectatic nevi, and birth marks are considered normal newborn skin variations.

On assessing a newborn, a nurse observes a separation of the abdominal muscles. That nurse recognizes the underlying case of this condition is which of the following?

Immature abdominal muscles SUBMIT ANSWER

What assessment finding alerts the nurse that the infant may have meningitis?

Opisthotonos (spasm of the muscles causing backward arching of the head, neck, and spine)

A nurse assesses an 8-month-old infant and observes an irregular shape to the infant's head. What assessment should the nurse perform next?

Palpate anterior fontanelle After observing an irregularly shaped head, the nurse should palpate for the anterior fontanelle because premature closure will cause the head to become irregular in shape. Then the nurse can perform further neurologic assessment of the infant to assess for deficits.

When assessing a newborn post vaginal delivery, the nurse observe bluish colored hands and feet. What is the nurse's priority action?

Place the newborn under the radiant warmer. The first action of the nurse is to place the infant under the radiant warmer. The hands and feet of the newborn may appear blue at times (acrocyanosis), which is normal, especially when the newborn is cold. With warming, skin color should return to pink. If the infant does not respond with warming techniques (placing newborn under radiant heater or adding a layer of blankets), consider a congenital heart defect in the newborn. The nurse should auscultate, not palpate, the apical pulse at the 4th intercostal space. The remaining options are premature and should be implemented when assessment warrants such actions.

During an assessment of a newborn, the nurse notes that the head of the baby's right femur slips out of the hip socket. How should the nurse document this finding?

Positive Barlow sign A feeling of the head of the femur slipping out of the hip socket is a positive Barlow sign. The Moro and stepping reflexes are not assessed by moving the baby's legs at the hip joints. The Harlequin sign is a skin marking.

The nurse learns that a new mother was upset after hearing about being pregnant and did not look forward to the birth of the baby. On what should the nurse focus when assessing the mother and the baby?

emotional attachment

While assessing a newborn infant, the nurse observes yellow-white retention cysts in the newborn's mouth. The nurse should explain to the infant's parents that these spots are usually indicative of

epstein pearls

What should a nurse expect to hear when auscultating a newborn's heart sounds? Select all that apply.

high pitched, loud, short

The nurse is preparing to palpate a 1-month old client's abdomen. What technique should the nurse use to facilitate this assessment?

hold the legs flexed at the knees and hips A useful technique to relax the infant to assess the abdomen is to hold the legs flexed at the knees and hips with one hand and palpate the abdomen with the other. Removing the diaper will not facilitate the abdominal assessment. The infant will not be easily distracted at this age by a toy. It will be difficult to determine abdominal organs if the abdomen is being assessed while being held by the mother.

A nurse inspects the anus of a newborn. Which of the following findings should be referred immediately to a specialist?

imperforate anus

A newborn male is diagnosed with undescended testicles. If left untreated, what health problem is this child at risk for developing? Select all that apply.

infertility Testicular cancer Testicular atrophy

Parents bring a 4-month-old to the clinic for a checkup. The mother tells the nurse that the infant is exclusively breast-fed. The nurse should assess the infant's need for which of the following?

iron supplements The AAP recommends that iron-fortified formulas be used for infants. These formulas are considered acceptable nutrition substitutes when breastfeeding is not chosen or not possible.

A nurse assesses a newborn and finds fine, downy hair all over the newborn's skin. How should the nurse document this finding?

languo

A mother of a newborn expresses concern to the nurse that her baby's eyes appear blue but both she and the baby's father have brown eyes. How should the nurse respond to the mother's concern?

"Permanent eye color will appear about 9 months of age." Typically, the iris of the eye is blue in light-skinned infants and brown in dark-skinned infants. Permanent eye color develops around 9 months of age. The grandparents' eye color would not impact the infant's eye color at birth. Telling the mother not to worry does not answer the question or make the mother feel comfortable. There is nothing wrong with the infant's pupils, so a check is not necessary.

A nurse is assessing a 9-month-old and finds that the infant's sucking reflex is still intact. At what age does this reflex normally disappear?

10 to 12 months

The anterior fontanelle of a neonate closes between

12-18 months The anterior fontanelle usually measures 4 to 6 cm at birth and closes between 12 and 18 months.

A mother visits the clinic with her 2-month-old son for a routine visit. The mother has been bottle feeding the infant and asks the nurse, "When can I start giving him solid foods?" The nurse should instruct the mother that solid foods can be introduced when the infant is

4-6 months

A nurse performs, measures, and documents the findings of the initial newborn assessment. Which data should the nurse recognize as an abnormal finding in the newborn?

A head circumference of 30 cm in a newborn is an abnormal finding. The normal head circumference is 33 to 35.5 cm. The newborn usually weighs between 2500 to 4000 g. The normal length of the newborn is 44 to 55 cm and the chest circumference is 30 to 33 cm.

Which action by the nurse demonstrates the correct technique to elicit Ortolani's maneuver?

Abduct the legs and move the knees outward The nurse should abduct the legs and move the knees outward to elicit Ortolani's maneuver. Barlow's maneuver involves adducting the legs until the thumbs of the nurse touch. Assessing the symmetry of the gluteal fold is done to look for hip dysplasia but is not a part of Ortolani's maneuver. The buttocks are spread with gloved hands to examine the anus.

A nurse assigns an Apgar score to a newborn baby at 5 minutes after delivery. Which parameter should the nurse recognize as an abnormal finding?

Apical pulse is less than 100 beats per minute

Which action by the nurse demonstrates the correct technique of assessing for the square window sign?

Bend wrist toward ventral forearm

The nurse practitioner is using an otoscope to assess the ears of a 1-year-old. What would it be important for the nurse practitioner to do?

Brace the hand holding the otoscope against the infant's face The nurse always braces the hand holding the otoscope against the infant's face, so that if the infant moves, the otoscope moves with him or her to avoid injuring the tympanic membrane. "Pull the ear lobe up and back" is for assessing the ears of an adult. "Have the infant supine with the head held by the nurse" and "Have the infant sit with the head held by the nurse" are incorrect, the parent would hold the infant's head while the infant sits on the parent's lap.

A nurse walks to a mother's room to assess a newborn that is 8 hours old and notices that the hands and feet are cyanotic in appearance. The baby is sleeping but is uncovered on the mother's chest. The nurse recognizes this finding is due to what physiologic occurrence?

Circulation is decreased because the newborn has been uncovered The bluish discoloration of the newborn's extremities is called acrocyanosis. It is common in newborns and usually occurs when the infant is cold. Skin color of the hands and feet should return to pink when warmed. The exact cause is unknown but the current line of thinking is that vasospasms in the cutaneous arteries and arterioles produce cyanotic discoloration. If any of the newborn's vital signs are changed, the nurse needs to perform further cardiovascular assessment.

The nurse is admitting an 8-month-old infant to the pediatric unit. Vital signs are T 36.4oC (97.5oF), heart rate 160 bpm, and respiratory rate 38/min. The client exhibits circumoral cyanosis and nasal flaring. Auscultation reveals diminished lung sounds in the bases of both lungs and grunting. What nursing diagnosis would be appropriate when writing the care plan for this child?

Inadequate gas exchange related to pneumonia The first sign of respiratory distress in a newborn is often tachypnea (heart rate greater than 160 at rest). Moderate respiratory distress includes nasal flaring, retractions of the chest wall, grunting auscultated with a stethoscope, cyanosis on room air, and abnormal blood gas values. Severe distress is indicated by increasing work of breathing, deep retractions, audible grunting, and central cyanosis. Nothing in the scenario indicates cardiac decompensation or inadequate tissue perfusion related to heart rate. While the client is having difficulty breathing, the child is not totally unable to breathe.

During a physical examination a 4-month old baby begins to cry. Which assessment finding should the nurse expect at this time?

Increased intracranial pressure produces a bulging, full anterior fontanelle and is seen when a baby cries. By age 4 months the posterior fontanelle should be closed. The average heart rate of a 4-month old should be between 80 and 180 beats per minute. The respiratory rate for this baby should be less than 50 breaths per minute.

A mother brings her 2-month-old infant to the health care facility with a high temperature. Which action by the nurse demonstrates the proper way to safely measure the rectal temperature in the baby?

Insert the thermometer no more than 2 cm into the rectum The rectal temperature is most accurate. The nurse should insert the lubricated rectal thermometer no more than 2 cm into the rectum when taking the rectal temperature. The baby should be in the supine position and not in the prone position when assessing rectal temperature. The newborn's legs should be bent at the hip, not at the knees. Temperature registers in 3 to 5 minutes, not 1 minute, on a rectal thermometer.

Which action by the nurse demonstrates the correct technique to assess the anus?

Spread the buttocks with gloved hands SUBMIT ANSWER

The nurse determines that a newborn has intact low-frequency hearing. What finding caused the nurse to make this clinical determination?

Stopped moving all extremities when being sung a lullaby Newborns respond to low-frequency sounds, such as a lullaby, by decreasing crying and motor movement. The newborn should decrease crying and motor movement when placed near the low-frequency sound of a heartbeat. A finger in the mouth could indicate that the baby is hungry. This action does not help identify level of hearing. Waving the arms when hands are clapped near the ears is a response to a high-frequency sound.

A group of students is preparing a class presentation on infant sleeping and Sudden Infant Death Syndrome. The presentation would include which of the following?

Teach parents about placing the baby on his back to sleep.

The nurse notes that a 3-week old baby's temperature is 100.50F. For which reason should the nurse be unconcerned about this temperature elevation?

The baby was crying An infant's temperature should be around 99.4oF. The temperature may be altered by crying. The temperature would not be altered by sleep, feeding, or being held by the mother.

A client brings in her 5-month-old for a "stuffy nose." While the infant is being examined, the parent states, "Why does my baby still have a hard time holding his head up?" What does the nurse understand about this milestone?

The infant should be able to hold the head up without support by 4 months of age.

A nurse inspects the external genitalia of a newborn girl who was born by breech vaginal delivery. Which of the following findings should be a cause of concern?

The labia majora and minora should be pink and moist. The newborn's genitalia may appear prominent because of influence of maternal hormones. Bruises and swelling may be caused by breech vaginal delivery. Pseudomenstruation (blood-tinged discharge) and smegma (cheesy, white discharge) of the sebaceous gland are also normal findings. However, an enlarged clitoris in a newborn combined with fusion of the posterior labia majora suggests ambiguous genitalia.

While assessing a 6-week-old infant new to the clinic, the nurse notices that the infant's ears fall below the imaginary line that runs from the inner canthus of the eye to the outer canthus and ear. What might indicate to the nurse that this finding is a normal variant in this case?

The mother has low-set ears. It may be helpful to note if either parent has low-set ears. If so, then the low-set ears may be an inherited normal variant. None of the remaining options present accurate information regarding an infant's ears.

The newborn receives an Apgar score of 9 at 1 minute and 10 at 5 minutes. What do these scores indicate to the nurse?

The newborn is adapting well to the extrauterine environment. The Apgar score is one of the first newborn assessments the nurse makes. It is not used to guide resuscitation efforts but gives important clues about how well the newborn is adapting to life outside of the womb. The newborn receives a score of 0 to 2 in each of five areas for a possible total score of 10. A score of 7 to 10 indicates a vigorous newborn adapting well to the extrauterine environment.

What should a nurse keep in mind when palpating for the testes in a male infant?

Touch or cold may pull the testicles back into the inguinal canal

Normal breathing pattern for a full-term infant may include

abdominal/chest breathing movements at a rate of 30 to 60 breaths/minute.

Normal breathing pattern for a full-term infant may include

abdominal/chest breathing movements at a rate of 30 to 60 breaths/minute. SUBMIT ANSWER

During examination of a newborn, the nurse strokes the lateral edge and ball of the newborn's foot so that the toes fan. What reflex is the nurse eliciting from this action?

babinski

A nurse examines a 6-month-old infant. The persistence of which reflex should the nurse recognize as abnormal?

moro

A nurse auscultates the chest of a newborn. The nurse hears breath sounds that are loud and harsh. Which of the following does this finding most likely indicate?

normal

A nurse assesses a 3-month-old infant and finds the foreskin tightened around the glans penis in a retracted position. Which term should the nurse use to document this finding in the medical record?

paraphimosis The nurse should document the finding as paraphimosis. Hypospadias is the presence of a urinary meatus on ventral surface of the glans, which is congenital. Epispadiasis is the presence of a urinary meatus on the dorsal surface of the glans. Phimosis refers to unretractable foreskin of the penis.

The nurse is conducting a wellness visit with a 2-month-old baby. Which finding should the nurse expect when assessing this client?

posterior fontanelle closed (closes at 2 months)

To obtain the most accurate temperature on an infant, a nurse should use which method?

rectal

The nurse begins the assessment of a 1-month-old baby. What should the nurse do first when weighing this client?

remove all clothes

Parents bring an 8-month-old boy to the emergency department, reporting that their child "just is not acting right." Nursing assessment shows that the infant's pulse is 165 beats/min. Respiratory rate, blood pressure, and temperature are within normal limits. Mild nasal flaring is noted. What should the nurse suspect?

respiratory distress Most emergent situations for the newborn involve respiratory decompensation. Signs of newborn respiratory distress include increased respiratory and heart rates, nasal flaring, and intercostal and substernal retractions. The first sign of respiratory distress in a newborn is often tachypnea (heart rate greater than 160 at rest). The child is not exhibiting cardiac decompensation, foreign body in trachea, or sepsis.

The nurse is performing a routine newborn assessment and gently strokes the cheek of the baby. The newborn turns toward the stroke and opens the mouth. What is this reflex called?

rooting

During examination of a newborn, the nurse touches the upper lip so that the newborn will move the head towards the stimulated area and open the mouth. What reflex is the nurse eliciting from this action?

rooting The nurse is eliciting the rooting reflex in the baby. The sucking reflex is assessed by placing a nipple in the newborn's mouth. The plantar reflex is assessed by touching the ball of the newborn's foot so that the toes curl downwards tightly. The palmar reflex is elicited by pressing the fingers against the palmar surface of the newborn's hands from the ulnar side.

The nurse is planning to instruct a first time mother about her newborn. The nurse should plan to instruct the mother that the newborn

they are obligate nose breathers