Pretest Pearson: Newborn assessment
The nurse is assessing a newborn infant. Which assessment finding would indicate the need for immediate intervention? Retractions Central cyanosis Grunting Nasal flaring
Central cyanosis Rationale Central cyanosis is a sign of severe respiratory distress and would require immediate intervention by the nurse. Nasal flaring, grunting, and retractions may indicate respiratory distress and may require close monitoring by the nurse, but not, perhaps, immediate intervention.
The nursery has been informed of the completion of an uncomplicated vaginal delivery at 3:30 p.m. The nurse prepares for her assessment of the newborn. When should this assessment be performed? By 5:30 p.m. By 4:30 p.m. By 6:30 p.m. At change of shift
By 5:30 p.m. Rationale The assessment of the newborn should be performed within 2 hr of birth. It can be completed within 1 hr, but with an uncomplicated delivery it is not necessary. The 2 hr after delivery can be used as beneficial bonding time with the parents. It is not appropriate to wait until the nurse's change of shift to complete the assessment.
The nurse is assessing baby boy Henry, who is 2 hr old. She notes that Henry's plantar creases cover his entire foot. Based on this information, what does the nurse determine Henry's gestational age to be? 36 weeks Full term Preterm 32 weeks
Full term Rationale One to two creases appear at approximately 32 weeks gestation. By 36 weeks gestation, creases cover the anterior two thirds of the foot. At term, creases cover the entire foot. For extremely preterm infants, the nurse measures the foot length from the tip of the great toe to the back of the heel.
The nurse is evaluating a new mother following a teaching session. The mother gently brushes the infant's cheek with her nipple and the newborn turns toward that side and opens the lips to suck. This demonstration of the rooting reflex is part of which assessment? Vital signs Apgar score Physical maturity assessment Neuromuscular .
Neuromuscular Rationale The rooting reflex is a neuromuscular characteristic and is elicited when the side of the newborn's mouth or cheek is touched. In response, the newborn turns toward that side and opens the lips to suck. Neuromuscular characteristics evaluate the physiological maturity of the newborn. The Apgar score is used to evaluate the physical condition of the newborn and determine the need for immediate resuscitation. Physical characteristics are objective, clinical criteria used to determine gestational age. Vital signs include respirations, apical heart rate, temperature, and blood pressure, if indicated.
The nurse is trying to determine whether a newborn is appropriate for gestational age (AGA). Which data collected during the physical assessment will help the nurse determine this classification for the newborn? Plantar creases present on anterior two thirds of sole Anterior and posterior fontanels nonbulging Milia present on bridge of nose Umbilical cord moist to touch
Plantar creases present on anterior two thirds of sole Rationale When determining newborn gestational age, points are given for each area of assessment, with a low of -1 or -2 for extreme immaturity to as high as 4 or 5 for postmaturity. Areas of assessment include skin texture, lanugo, plantar creases, breast tissue, eyes and ears, and genitalia.
The nurse is assessing a sleeping, 1-hr-old newborn. Which data would necessitate the need to notify the healthcare provider? Brief periods of apnea lasting less than 5 seconds Heart rate 122 beats/min Respirations 78 breaths/min Temperature 97.9°F
Respirations 78 breaths/min Rationale The normal temperature range for a newborn is 97.5° to 99°F. The nurse should not report this temperature as an abnormal finding of concern. Normal respiratory rate is 30dash60 breaths/min. Seventy-eight respirations per minute could represent a less-than-expected transition. The nurse should notify the healthcare provider of this pattern of breathing. It is normal for the newborn to exhibit brief periods of apnea lasting less than 15 seconds. This should not be reported to the healthcare provider unless the periods of apnea last longer or the infant's vital signs become unstable. This heart rate is within the normal range of 110dash160 beats/min
A preterm infant arrives in the nursery. Which initial assessments will the nurse make on this infant? (Select all that apply.) Signs of respiratory distress Blood glucose monitoring Core temperature readings . Gestational age determination Complete blood count
Signs of respiratory distress Core temperature readings . Gestational age determination Rationale Accurate assessment of the gestational age of the preterm newborn is imperative to anticipate special needs and problems. Gestational age assessment should be performed on all newborns. Premature infants may exhibit alterations in thermoregulation, are more prone to hypothermia, and need core temperature readings. Premature infants may exhibit alterations in all body systems and are more likely to encounter respiratory issues than term infants. Blood glucose monitoring and a complete blood count may be done but are not part of the essential assessments that need to be performed initially.
The nurse is caring for a newborn who is small for gestational age (SGA). The newborn's parents ask the nurse how this happened. Which rationales will the nurse use to respond to these parents? (Select all that apply.) The newborn may have suffered from intrauterine growth restriction (IUGR). The newborn's head circumference is in the 50th percentile. The newborn's weight falls below the 10th percentile. The newborn weighs less than 2,500 g (5.5 lb). The newborn had intrauterine exposure to bacteria.
The newborn may have suffered from intrauterine growth restriction (IUGR). The newborn's weight falls below the 10th percentile. Rationale Infants classified as small for gestational age (SGA) may have intrauterine growth restriction (IUGR), which can be related to multiple etiologies, although the terms SGA and IUGR are not necessarily interchangeable. Infants whose weight is below the 10th percentile are diagnosed as SGA. Babies can weigh less than 5 lb 8 oz (2,500 g) because of gestational age and still be classified as appropriate for gestational age or large for gestational age. Infants whose head circumference is below the 10th percentile are diagnosed as SGA. Intrauterine exposure to bacteria is not associated with infants who are SGA
