Ch 27 NB Assessment

1. A normal position

8) The nurse assesses the newborns ears to be parallel to the outer and inner canthus of the eye. The nurse documents this finding to be which of the following? 1. A normal position 2. A possible chromosomal abnormality 3. Facial paralysis 4. Prematurity

1. His head is molded from fitting through the birth canal. It will become more round.

10) The nurse is preparing new parents for discharge with their newborn. The father asks the nurse why the babys head is so pointed and puffy-looking. What is the best response by the nurse? 1. His head is molded from fitting through the birth canal. It will become more round. 2. We refer to that as cone head, which is a temporary condition that goes away. 3. It might mean that your baby sustained brain damage during birth, and could have delays. 4. I think he looks just like you. Your head is much the same shape as your babys.

2. This assessment looks at both physical aspects and the nervous system.

13) The nurse is completing the gestational age assessment on a newborn while in the mothers postpartum room. During the assessment, the mother asks what aspects of the baby are being checked. What is the nurses best response? 1. Im checking to make sure the baby has all of its parts. 2. This assessment looks at both physical aspects and the nervous system. 3. This assessment checks the babys brain and nerve function. 4. Dont worry. We perform this check on all the babies.

1. Sole creases 2. Amount of breast tissue 3. Amount of lanugo 5. Testicular descent

16) The nurse is assessing the gestational age of a 1-hour-old newborn. Which physical characteristics does the nurse assess? Select all that apply. 1. Sole creases 2. Amount of breast tissue 3. Amount of lanugo 4. Reflexes 5. Testicular descent

3. Telangiectatic nevi

17) During an assessment of a 12-hour-old newborn, the nurse notices pale pink spots on the nape of the neck. The nurse documents this finding as which of the following? 1. Nevus vasculosus 2. Nevus flammeus 3. Telangiectatic nevi 4. A Mongolian spot

1. It is normal for the posterior fontanelle to close by 8 to 12 weeks after birth.

18) The mother of a 16-week-old infant calls the clinic concerned because she cannot feel the posterior fontanelle on her infant. Which response by the nurse would be most appropriate? 1. It is normal for the posterior fontanelle to close by 8 to 12 weeks after birth. 2. Bring your infant to the clinic immediately. 3. This is due to overriding of the cranial bones during labor. 4. Your baby must be dehydrated.

1. Caput succedaneum

19) Which of the following is a localized, easily identifiable soft area of the infants scalp, generally resulting from a long and difficult labor or vacuum extraction? 1. Caput succedaneum 2. Cephalohematoma 3. Molding 4. Depressed fontanelles

1. Amount and area of vernix coverage

2) Before the nurse begins to dry off the newborn after birth, which assessment finding should the nurse document to ensure an accurate gestational rating on the Ballard gestational assessment tool? 1. Amount and area of vernix coverage 2. Creases on the sole 3. Size of the areola 4. Body surface temperature

1. Brazelton Neonatal Behavioral Assessment Scale

2) The nurse wishes to demonstrate to a new family their infants individuality. Which assessment tool would be most appropriate for the nurse to use? 1. Brazelton Neonatal Behavioral Assessment Scale 2. New Ballard Score 3. Dubowitz gestational age scale 4. Ortolani maneuver

2. Moving the foot to midline and determining resistance.

20) The nurse suspects clubfoot in the newborn and assesses for the condition by doing which of the following? 1. Adducting the foot and listening for a click. 2. Moving the foot to midline and determining resistance. 3. Extending the foot and observing for pain. 4. Stimulating the sole of the foot.

1. The fontanelles can swell with crying. 3. The fontanelles can pulsate with the heartbeat. 5. The fontanelles can swell when stool is passed.

21) A new mother is concerned because the anterior fontanelle swells when the newborn cries. Explaining normal findings concerning the fontanelles, the nurse states which of the following? Select all that apply. 1. The fontanelles can swell with crying. 2. The fontanelles might be depressed. 3. The fontanelles can pulsate with the heartbeat. 4. The fontanelles might bulge. 5. The fontanelles can swell when stool is passed.

3. The student nurse determines skin color, then describes the shape of the chest and looks at structures and flexion of the feet

22) The nurse is working with a student nurse during assessment of a 2-hour-old newborn. Which action indicates that the student nurse understands neonatal assessment? 1. The student nurse listens to bowel sounds then assesses the head for skull consistency and size and tension of fontanelles. 2. The student nurse checks for Ortolanis sign, then palpates the femoral pulse, then assesses respiratory rate. 3. The student nurse determines skin color, then describes the shape of the chest and looks at structures and flexion of the feet. 4. The student nurse counts the number of cord vessels, then assesses genitals, then sclera color and eyelids.

3. 70% to 75%

23) Approximately what percentage of the newborns body weight is water? 1. 5% to 10% 2. 90% to 95% 3. 70% to 75% 4. 50% to 60%

1. Acrocyanosis

24) What condition is due to poor peripheral circulation? 1. Acrocyanosis 2. Mottling 3. Harlequin sign 4. Jaundice

2. Plantar creases over entire sole 5. Testes are pendulous, and the scrotum has deep rugae

25) The nurse determines the gestational age of an infant to be 40 weeks. Which characteristics are most likely to be observed? Select all that apply. 1. Lanugo abundant over shoulders and back 2. Plantar creases over entire sole 3. Pinna of ear springs back slowly when folded. 4. Vernix well distributed over entire body 5. Testes are pendulous, and the scrotum has deep rugae

3. Newborns have an initial weight loss in the first 3 to 4 days. Your babys weight loss is normal. 5. Keep the baby from getting chilled or too warm because that can contribute to weight loss.

26) A breastfeeding mother calls the pediatric clinic concerned about her 4-day-old babys failure to gain weight. She states that the infant has lost several ounces since birth. The most appropriate response by the nurse would be which of the following? Select all that apply. 1. Newborns tend to lose about 5% to 10% of their birth weight because of failure to give adequate supplements when breastfeeding. 2. Newborns grow approximately 1 inch a month in the first 6 months. You will need to increase feedings to compensate for the growth spurt. 3. Newborns have an initial weight loss in the first 3 to 4 days. Your babys weight loss is normal. 4. Newborns lose a lot of heat, so make sure you keep the babys formula warm when you supplement the breast milk. 5. Keep the baby from getting chilled or too warm because that can contribute to weight loss.

3. Clavicle

27) The nurse attempts to elicit the Moro reflex on a newborn, and assesses movement of the right arm only. Based on this finding, the nurse immediately assesses for which of the following? 1. Ortolani maneuver 2. Palmar grasping reflex 3. Clavicle 4. Tonic neck reflex

1. The mass appeared on the second day after birth. 2. The mass appears larger when the newborn cries. 3. The head appears asymmetrical. 4. The mass appears on only one side of the head

3) A new mother is concerned about a mass on the newborns head. The nurse assesses this to be a cephalohematoma based on which characteristics? Select all that apply. 1. The mass appeared on the second day after birth. 2. The mass appears larger when the newborn cries. 3. The head appears asymmetrical. 4. The mass appears on only one side of the head. 5. The mass overrides the suture line.

1. Muscle tone is assessed by moving various parts of the newborns body while the newborns head remains in a neutral position. 2. The newborn is somewhat hypertonic. 3. Muscle tone should be symmetrical. 5. Diminished muscle tone requires further evaluation.

30) When doing a neurologic assessment of a newborn, what would the nurse recognize? Select all that apply. 1. Muscle tone is assessed by moving various parts of the newborns body while the newborns head remains in a neutral position. 2. The newborn is somewhat hypertonic. 3. Muscle tone should be symmetrical. 4. Shortly after birth, the infant is flaccid at rest. 5. Diminished muscle tone requires further evaluation.

3. When I put my finger in the palm of my daughters hand, she will curl her fingers and hold on.

31) The nurse is completing a newborn care class. The nurse knows that teaching has been effective if a new parent states which of the following? 1. My baby might open her arms wide and pull her legs up to her tummy if she is passing gas. 2. When I hold my baby upright with one of his feet on the floor, his feet will automatically remain still. 3. When I put my finger in the palm of my daughters hand, she will curl her fingers and hold on. 4. I can get my baby to turn his head toward the right if I lift his right arm over his head.

4. 4 months

33) A new parent reports to the nurse that the baby looks cross-eyed several times a day. The nurse teaches the parents that this finding should resolve in how long? 1. 2 months 2. 2 weeks 3. 1 year 4. 4 months

4. Newborns in a noisy nursery are able to habituate to the sounds, and might not react unless a sound is sudden or much louder.

34) A mother notices that her newborn is able to sleep without waking even when in the nursery with other newborns crying. The mother asks whether her baby might have a hearing problem because her father wears hearing aids. What should the nurse explain? 1. Newborn risk factors associated with potential hearing loss do not include a family history of hearing loss. 2. Newborns cannot hear, due to mucus accumulated in the middle ear, which takes several days to drain. 3. Newborns who are asleep do not respond to loud noises that are not accompanied by vibrations. 4. Newborns in a noisy nursery are able to habituate to the sounds, and might not react unless a sound is sudden or much louder.

2. Hypoglycemia 3. Hypocalcemia 4. Substance withdrawal 5. Neurologic damage

35) When assessing a full-term newborn, the nurse notes tremorlike movements. The nurse is aware that further evaluation is indicated to rule out which of the following? Select all that apply. 1. Hyperglycemia 2. Hypoglycemia 3. Hypocalcemia 4. Substance withdrawal 5. Neurologic damage

1. The behavioral assessment should be done as soon after birth as possible. 2. The behavioral assessment can be performed without input from parents.

36) The nurse is cross-training maternal-child health unit nurses to provide home-based care for parents after discharge. Which statements indicate that additional teaching is required? Select all that apply. 1. The behavioral assessment should be done as soon after birth as possible. 2. The behavioral assessment can be performed without input from parents. 3. The behavioral assessment might be incomplete in a 1-hour home visit. 4. The behavioral assessment includes orientation and motor activity. 5. The behavioral assessment can detect neurological impairments.

4. Cuddliness is a social behavior that some babies have.

37) The parents of a newborn comment to the nurse that their infant seems to enjoy being held, and that holding the baby helps him calm down after crying. They ask the nurse why this happens. After explaining newborn behavior, the nurse assesses the parents learning. Which statement indicates that teaching was effective? 1. Some babies are easier to deal with than others. 2. We are lucky to have a baby with a calm disposition. 3. Our baby spends more time in the active alert phase. 4. Cuddliness is a social behavior that some babies have.

1. Identification of responses or activities that best meet the special needs of their newborn. 4. Positive attachment experiences. 5. Understanding of the newborns various behaviors.

38) The parents are asking the nurse about their newborns behavior. The nurse begins to teach the parents about their newborn and involve them in their babys care. What are these interventions directed at promoting to the parents? Select all that apply. 1. Identification of responses or activities that best meet the special needs of their newborn. 2. Ability to evaluate the neurologic capacity of their newborn. 3. Understanding that the babys temperament will be the same as their own. 4. Positive attachment experiences. 5. Understanding of the newborns various behaviors.

1. Habituation 2. Motor activity 3. Self-quieting activity 4. Cuddliness

39) The nurse is explaining to a new mother that the newborn behavioral assessment includes which of the following? Select all that apply. 1. Habituation 2. Motor activity 3. Self-quieting activity 4. Cuddliness 5. Reflexes

2. Prominent clitoris, enlarging minora, anus patent

5) The student nurse has performed a gestational age assessment of an infant, and finds the infant to be at 32 weeks. On which set of characteristics is the nurse basing this assessment? 1. Lanugo mainly gone, little vernix across the body 2. Prominent clitoris, enlarging minora, anus patent 3. Full areola, 5 to 10 mm bud, pinkish-brown in color 4. Skin opaque, cracking at wrists and ankles, no vessels visible

1. Chest circumference 31.5 cm, head circumference 33.5 cm

6) The nurse is making an initial assessment of the newborn. Which of the following data would be considered normal? 1. Chest circumference 31.5 cm, head circumference 33.5 cm 2. Chest circumference 30 cm, head circumference 29 cm 3. Chest circumference 38 cm, head circumference 31.5 cm 4. Chest circumference 32.5 cm, head circumference 36 cm

4. 4 months

7) A new parent reports to the nurse that the baby looks cross-eyed several times a day. The nurse teaches the parents that this finding should resolve in how long? 1. 2 months 2. 2 weeks 3. 1 year 4. 4 months

1. Cephalohematoma

9) The nurse assesses four newborns. Which of the following assessment findings would place a newborn at risk for developing physiologic jaundice? 1. Cephalohematoma 2. Mongolian spots 3. Telangiectatic nevi 4. Molding

1. Place a gloved finger in the newborns mouth.

11) The student nurse attempts to take a newborns vital signs, but the newborn is crying. What nursing action would be appropriate? 1. Place a gloved finger in the newborns mouth. 2. Take the vital signs. 3. Wait until the newborn stops crying. 4. Place a hot water bottle in the isolette.

. Document the findings in the chart.

14) The nurse is making an initial assessment of the newborn. The findings include a chest circumference of 32.5 cm and a head circumference of 33.5 cm. Based on these findings, which action should the nurse take first? 1. Notify the physician. 2. Elevate the newborns head. 3. Document the findings in the chart. 4. Assess for hypothermia immediately.

3. The red spots with a white center on my baby are abnormal acne.

15) The nurse is teaching a class on infant care to new parents. Which statement by a parent indicates that additional teaching is needed? 1. The white spots on my babys nose are called milia, and are harmless. 2. The whitish cheeselike substance in the creases is vernix, and will be absorbed. 3. The red spots with a white center on my baby are abnormal acne. 4. Jaundice is a yellowish discoloration of skin that if noticed on the 1st day of life should be reported to the physician.

4. The right arm is flaccid while the infant brings the left arm and fist upward to the head.

28) The nurse is preparing to assess a newborns neurological status. Which finding would require an immediate intervention? 1. At rest, the infant has partially flexed arms and the legs drawn up to the abdomen. 2. When the corner of the mouth is touched, the infant turns the head that direction. 3. The infant blinks when the exam light is turned on over the face and body. 4. The right arm is flaccid while the infant brings the left arm and fist upward to the head.

1. State of alertness 3. Quality of muscle tone 4. Cry 5. Motor activity

29) Which of the following are important behaviors to assess in the neurologic assessment? Select all that apply. 1. State of alertness 2. Active posture 3. Quality of muscle tone 4. Cry 5. Motor activity

2. This baby might not have a rooting or sucking reflex because she is premature.

32) The nurse is working with a mother who has just delivered her third child at 33 weeks gestation. The mother says to the nurse, This baby doesnt turn his head and suck like the older two children did. Why? What is the best response by the nurse? 1. Every baby is different. This is just one variation of normal that we see on a regular basis. 2. This baby might not have a rooting or sucking reflex because she is premature. 3. When she is wide awake and alert, she will probably root and suck even if she is early. 4. She might be too tired from the birthing process and need a couple of days to recover.

3. Ear cartilage folded over, lanugo present over much of the body, slow recoil t

4) The nurse is using the New Ballard Score to assess the gestational age of a newborn delivered 4 hours ago. The infants gestational age is 33 weeks based on early ultrasound and last menstrual period. The nurse expects the infant to exhibit which of the following? 1. Full sole creases, nails extending beyond the fingertips, scarf sign showing the elbow beyond the midline 2. Testes located in the upper scrotum, rugae covering the scrotum, vernix covering the entire body 3. Ear cartilage folded over, lanugo present over much of the body, slow recoil time 4. 1 cm breast bud, peeling skin and veins not visible, rapid recoil of legs and arms to extension

1. Your baby will respond to you the most if you look directly into his eyes and talk to him.

40) The nurse is teaching a group of new parents about their infants. The infants are all 4 weeks of age or younger. Which statement should the nurse include? 1. Your baby will respond to you the most if you look directly into his eyes and talk to him. 2. Each baby is different. Dont try to compare your infants behavior with any other childs behavior. 3. If the sound level around your baby is high, the baby will wake up and be fussy or cry. 4. If your baby is a cuddler, it is because you rocked and talked to her during your pregnancy.

1. Mother of a 2-week-old infant who doesnt make eye contact when talked to

41) The nurse is answering phone calls at the pediatric clinic. Which call should the nurse return first? 1. Mother of a 2-week-old infant who doesnt make eye contact when talked to 2. Father of a 1-week-old infant who sleeps through the noise of an older sibling 3. Father of a 6-day-old infant who responds more to mothers voice than to fathers voice 4. Mother of a 3-week-old infant who has begun to suck on the fingers of the right hand

1. Medium pitch 3. Strength 5. Lusty

42) The newborns cry should have which of the following characteristics? Select all that apply. 1. Medium pitch 2. Shrillness 3. Strength 4. High pitch 5. Lusty

1. Arm recoil

) A nursing instructor is demonstrating an assessment on a newborn using the Ballard gestational assessment tool. The nurse explains that which of the following tests should be performed after the first hour of birth, when the newborn has had time to recover from the stress of birth? 1. Arm recoil 2. Square window sign 3. Scarf sign 4. Popliteal angle