Newborns
Late preterm
34 0/7 - 36 6/7 weeks
Normal Ballard Scale Score and Age
35 to 45 points 38 to 42 weeks
Term
37 0/7 to 41 6/7
Neonate
From birth to 28 days
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.
While assessing a young infant's musculoskeletal system, the nurse anticipates that the anterior curve in the cervical region will be developed by
3 to 4 months.
When should palmer grasp reflex go away?
3-4 months
When should rooting reflex go away?
3-4 months
Para
# of births after 20 weeks gestation
Gravida
# of pregnancies
The nurse is assessing a 1-year-old infant who weighed 3.6 kg (8 lb) at birth. When the nurse prepares to weigh the infant, the nurse anticipates that this infant should weigh approximately
-10.8 kg (24 lb).
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 to 6 months old. -Solids are not recommended before 4 months of age due to the presence of the protrusion or sucking reflexes and the immaturity of the gastrointestinal tract and the immune system.
A nurse is assessing a newborn using Apgar scoring. The newborn demonstrates the following: a heart rate of 90 bpm; a good, lusty cry; grimaces on irritation; flaccid, limp muscle tone; and a pink body with acrocyanosis. How should the nurse score this client
-5 -The infant should be scored as follows: a heart rate of 90 bpm warrants a score of 1; a good, lusty cry warrants a score of 2; grimaces on irritation warrants a 1; flaccid, limp muscle tone warrants a 0; and a pink body with acrocyanosis warrants a 1. So, 1 + 2 + 1 + 0 + 1 = 5.
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 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 weight of 2000 g in a newborn is an abnormal finding. -The newborn usually weighs 2500 to 4000 g. -The normal head circumference is 33 to 35.5 cm. -The normal length of the newborn is 44 to 55 cm, and the chest circumference is 30 to 33 cm.
The nurse notes that a sleeping newborn's heart rate is 102 bpm. What action should the nurse take first?
-Document the heart rate -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.
The nurse assesses the skin of a 2-week-old infant. For which finding should the nurse notify the health care provider?
-Eight hyperpigmented macules over both legs -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.
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. -Epstein's pearls—small, yellow-white retention cysts on the hard palate and gums—are common in newborns and usually disappear in the first weeks of life.
Which action by the nurse demonstrates the correct technique of assessing for arm recoil?
-Flex the elbows up bilaterally -Flexing the elbows up bilaterally is done to test arm recoil. -Flexing the thigh on top of the abdomen is used to test the popliteal angle. -To assess for the square window sign, the nurse should bend the newborn's wrist towards the ventral forearm until resistance is met and the angle is measured. -Lifting the arm across the chest towards the opposite shoulder until resistance is met is done to elicit the Scarf sign.
The mother of a 9-month-old girl calls the clinic. She tells the nurse that her daughter has developed a rash. The nurse asks a series of questions to assess the rash. Why would it be important for the nurse to ask these questions?
-Helps pinpoint possible causes -These questions help pinpoint possible causes. Many skin conditions have predictable patterns of spread, parts of the body affected, and associated symptoms, such as pruritis (itching). It is important to differentiate if the symptoms are localized versus systemic or if there might be an infectious versus an allergic origin.
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.
On inspecting a newborn's breasts, the nurse notes that they are enlarged and engorged, with a white liquid discharge. The infant's mother is concerned about it. Which of the following should the nurse tell the mother regarding this finding?
-It is due to the influence of the maternal hormones and should resolve in a few days. -Newborns may have enlarged and engorged breasts with a white liquid discharge resulting from the influence of maternal hormones. This condition resolves spontaneously within days. None of the other answers is correct regarding this finding.
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 scaphoid (boat-shaped; i.e., sunken with prominent rib cage) abdomen may result from malnutrition or dehydration. A distended abdomen may indicate pyloric stenosis. A bulge at the umbilicus suggests an umbilical hernia. Diastasis recti (separation of the abdominal muscles) is seen as a midline protrusion from the xiphoid to the umbilicus or pubis symphysis. This condition is secondary to immature abdominal muscles and usually has little significance.
The nurse is performing an eye assessment on a newborn and is unable to elicit a red reflex. What is the priority intervention that the nurse should do at this time?
-Notify the physician. -The inability to elicit a red reflex from a newborn can be clinically significant. The infant should be referred to a specialist. Absence of a red reflex can indicate congenital cataracts or neuroblastoma.
What assessment finding alerts the nurse that the infant may have have meningitis?
-Opisthotonos -Opisthotonos is an indicator of meningitis and meningeal irritation. In this condition, the head and neck are in a severe state of hyperextension.
During the assessment of a 6 month old what finding would the nurse expect find?
-Posterior fontanelle is closed -The posterior fontanelle usually closes around 3 months. The anterior fontanelle usually closes between 9 and 18 months. Bulging is an indication of increased intracranial pressure or hydrocephalus.
A nurse auscultates the bowel sounds of a 1-month-old. Which of the following findings should warrant further assessment by the nurse?
-Presence of marked peristaltic waves -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.
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 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.
When assessing a newborn post vaginal delivery, the nurse observe bluish colored hands and feet. What is the nurse's priority action?
-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.
How should a nurse test visual acuity in an infant of 6 weeks of age?
-Watch to see if the infant can follow a moving object -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.
During a physical examination a 4-month old baby begins to cry. Which assessment finding should the nurse expect at this time?
-bulging anterior fontanelle -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.
During a physical examination a 4-month old baby begins to cry. Which assessment finding should the nurse expect at this time?
-bulging anterior fontanelle -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.
Motor development of an infant progresses
-cephalocaudally -Motor development refers to changes in the newborn's ability to control body movements. Motor development progresses in predictable patterns: cephalocaudally, central to distal, and gross to fine.
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.
When should sucking reflex go away?
10-12 months
When do you triple your birth weight?
12 months
Normal heart rate for newborns
120-160 bpm
When do you measure head circumference until?
18-24 months
When should stepping reflex go away?
2 months
When should Babinksi reflex go away?
2 years
Chest circumference
30-33cm
Normal respirations for newborns
30-60
Head circumference
33-35.5cm
Daily weight gain?
20-30g first 3-4 months 12-20g remainder of first 12 months
Normal respirations for 1 year
20-40
Normal weight for infant
2500-4000g
Infant
28 days to 1 year
When should moro (startle) reflex go away?
3 months
When do you double your birth weight?
4-5 months
When should swimming/parachute reflex go away?
4-6 months
When should tonic reflex go away?
4-6 months
Length at birth
44-55cm
When should plantar grasp reflex go away?
8-10 months
Normal heart rate for 1 year
80-160 bpm
Hyperthermia
Above 37.2 C or 99 F
Post-term
After 42 weeks
Respiratory distress
Below 30 or above 60 breaths/min
Hypothermia
Below 36.38 C or 97.5 F
When do you double length at birth?
By age 4
Sign of cardiac abnormalities
Irregular pulse below 100 or above 180 bpm
Early Preterm
Less than 32 weeks
Preterm
Less than 37 weeks
The nurse begins the assessment of a 1-month-old baby. What should the nurse do first when weighing this client?
Remove all clothing
Normal breathing pattern for a full-term infant may include
abdominal/chest breathing movements at a rate of 30 to 60 breaths/minute.
