Ch 27: Nursing Assessment of the Newborn
38) At birth a newborn weighed 7 pounds 10 ounces. If the average weight gain is 7 ounces every week for the first 6 months, what weight should the nurse expect when assessing an infant that is 20 weeks old? (Calculate the weight in ounces.)
Answer: 260 ounces Explanation: Multiply 7 ounces × 20 = 140 ounces. Divide the amount in ounces by 16 or 140/16 = 8.75. Convert 8.75 to pounds and ounces by using the equation 75/100 = x/16; 1200 = 100x; x= 12 ounces. Convert the birth weight to ounces: 7 × 16 = 112 + 10 = 122. Convert the weight gained over 20 weeks: 8 × 16 = 128 + 12 = 140. Add the two weights: 122 + 140 = 260. The baby should weigh 260 ounces by 20 weeks. Page Ref: 669
37) At birth a newborn's head circumference is 13 inches. What should the nurse expect the chest circumference to be in cm? (Round to the nearest whole number.)
Answer: 31 cm Explanation: The circumference of the newborn's head is approximately 2 cm greater than the circumference of the newborn's chest at birth. First determine the infant's head circumference in cm by multiplying 13 inches by 2.54 cm or 13 × 2.54 = 33.02 or 33 cm. If the chest circumference is 2 cm smaller than the head circumference, the nurse should expect the infant's chest to measure 31 cm. Page Ref: 669
36) At birth a newborn measured 20 inches. What length should the nurse instruct the mother to expect the baby to be at 4 months? (Calculate the anticipated length in cm and round to the nearest whole number.)
Answer: 61 c m Explanation: The conversion 2.54 cm = 1 inch will be used. If the initial length was 20 inches, convert this to cm by multiplying 20 × 2.54 = 50.8 cm. If the average growth is approximately one inch per month for the first 6 months, then multiply 2.54 × 4 = 10.16 cm and add this amount to the birth length of 50.8 cm or 10.16 cm + 50.8 cm = 60.96. With rounding, the mother can expect the infant to be 61 cm in length. Page Ref: 669
35) At 3 weeks a newborn weighs 8 lbs. 1 ounce. What percent of this body weight should the nurse explain to the mother as being water? (Calculate the average weight in ounces to the first decimal point.)
Answer: 93.5 ounces Explanation: Approximately 70% to 75% of the newborn's body weight is water. First determine the infant's weight in ounces by multiplying 8 × 16 ounces = 128 ounces + 1 ounce = 129 ounces. Then multiply the weight in ounces by 70% and then by 75%: 129 ounces × 70% = 90.3 ounces; 129 ounces × 75% = 96.75. Then add the values of 70% and 75% and divide by 2 to determine the average: 90.3 + 96.75 = 187.05/2 = 93.525 ounces. To determine this weight in pounds divide by 16, or 93.525/16 = 5.84 of the infant's weight is water. To determine the weight in pounds and ounces: .84/100 = x/16; 1344 = 100x; 1344/100 = 13.44 ounces. The percentage of the infant's weight that is water is 5 pounds, 13.44 ounces. Page Ref: 677
9) The nurse assesses four newborns. Which of the following assessment findings would place a newborn at risk for developing physiologic jaundice? A) Cephalohematoma B) Mongolian spots C) Telangiectatic nevi D) Molding
Answer: A Explanation: A) A cephalohematoma is a collection of blood resulting from ruptured blood vessels between the surface of a cranial bone and the periosteal membrane. They may be associated with physiologic jaundice, because there are extra red blood cells being destroyed within the cephalohematoma. B) Mongolian spots are macular areas of bluish-black pigmentation on the dorsal area of the buttocks. C) Telangiectatic nevi are pale pink or red spots found on the eyelids, nose, lower occipital bone, or nape of the neck. D) Molding is caused by overriding of the cranial bones. Page Ref: 675
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? A) 2 months B) 2 weeks C) 1 year D) 4 months
Answer: D Explanation: A) It usually takes a little longer than 2 months for transient strabismus to disappear. B) Transient strabismus lasts longer than 2 weeks. C) Transient strabismus generally does not last 1 year. D) Transient strabismus is caused by poor neuromuscular control of the eye muscles and gradually regresses in 3 to 4 months. Page Ref: 676
23) What condition is due to poor peripheral circulation? A) Acrocyanosis B) Mottling C) Harlequin sign D) Jaundice
Answer: A Explanation: A) Acrocyanosis is a bluish discoloration of the hands and feet that may be present in the first 24 hours after birth and is due to poor peripheral circulation, which results in vasomotor instability and capillary stasis, especially when the baby is exposed to cold. B) Mottling is a lacy pattern of dilated blood vessels under the skin and occurs as a result of general circulation fluctuations. C) Harlequin sign (clown) color change is a deep color that develops over one side of the newborn's body while the other side remains pale, so that the skin resembles a clown's suit. D) Jaundice is a yellowish discoloration of skin and mucous membranes first detectable on the face and the mucous membranes of the mouth. Page Ref: 671
1) 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? A) Arm recoil B) Square window sign C) Scarf sign D) Popliteal angle
Answer: A Explanation: A) Arm recoil is slower in healthy but fatigued newborns after birth; therefore, arm recoil is best elicited after the first hour of birth, when the baby has had time to recover from the stress of birth. B) The square window sign does not have to be assessed after the first hour of birth. C) The scarf sign does not have to be assessed after the first hour of birth. D) The popliteal angle does not have to be assessed after the first hour of birth. Page Ref: 665
12) The nurse wishes to demonstrate to a new family their infant's individuality. Which assessment tool would be most appropriate for the nurse to use? A) Brazelton Neonatal Behavioral Assessment Scale B) New Ballard Score C) Dubowitz gestational age scale D) Ortolani maneuver
Answer: A Explanation: A) Brazelton Neonatal Behavioral Assessment Scale is an assessment tool that identifies the newborn's repertoire of behavioral responses to the environment and documents the newborn's neurologic adequacy and capabilities. B) Ballard developed the estimation of gestational age by maturity rating. C) The Dubowitz assessment tool assesses physical characteristics and neurological or neuromuscular development. D) The Ortolani maneuver is an assessment technique to evaluate for hip dislocation or hip instability. Page Ref: 684
18) Which of the following is a localized, easily identifiable soft area of the infant's scalp, generally resulting from a long and difficult labor or vacuum extraction? A) Caput succedaneum B) Cephalohematoma C) Molding D) Depressed fontanelles
Answer: A Explanation: A) Caput succedaneum is a localized, easily identifiable soft area of the scalp, generally resulting from a long and difficult labor or vacuum extraction. B) Cephalohematoma is a collection of blood resulting from ruptured blood vessels between the surface of a cranial bone and the periosteal membrane. C) The head may appear asymmetric in the newborn who had a vertex presentation. This asymmetry (molding) is caused by the overriding of the cranial bones during labor and birth. D) A depressed fontanelle indicates dehydration. Page Ref: 675
2) Before drying off the newborn after birth, which assessment finding should the nurse document to ensure an accurate gestational rating on the Ballard gestational assessment tool? A) Amount and area of vernix coverage B) Creases on the sole C) Size of the areola D) Body surface temperature
Answer: A Explanation: A) Drying the baby after birth will disturb the vernix and potentially alter the gestational age criterion. The nurse should document the amount and areas of vernix coverage before drying the newborn. B) Creases on the sole are not affected by drying the newborn. C) The size of the areola is not affected by drying the newborn. D) Body surface temperature is not part of the Ballard gestational assessment tool. Page Ref: 664
6) The nurse is making an initial assessment of the newborn. Which of the following data would be considered normal? A) Chest circumference 31.5 cm, head circumference 33.5 cm B) Chest circumference 30 cm, head circumference 29 cm C) Chest circumference 38 cm, head circumference 31.5 cm D) Chest circumference 32.5 cm, head circumference 36 cm
Answer: A Explanation: A) The average circumference of the head at birth is 32 to 37 cm. Average chest circumference ranges from 30 to 35 cm at birth. The circumference of the head is approximately 2 cm greater than the circumference of the chest at birth. Answer 1 is the only choice in which both the chest and head circumferences fall within the norm in terms of actual size and comparable size. Page Ref: 669
32) 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? A) "Your baby will respond to you the most if you look directly into his eyes and talk to him." B) "Each baby is different. Don't try to compare your infant's behavior with any other child's behavior." C) "If the sound level around your baby is high, the baby will wake up and be fussy or cry." D) "If your baby is a cuddler, it is because you rocked and talked to her during your pregnancy."
Answer: A Explanation: A) The parents' visual (en face) and auditory (soft, continuous voice) presence stimulates their infant to orient to them. B) Although each infant is unique, there are certain predictable norms to observe for when assessing for neurological normalcy or impairment. C) Some infants become overstimulated when excessive noise is present, but more habituate to the sound and sleep. D) Cuddling is a social behavior that correlates with personality, but it has not been linked to any prenatal activities. Page Ref: 684
8) The nurse assesses the newborn's ears to be parallel to the outer and inner canthus of the eye. The nurse documents this finding to be which of the following? A) A normal position B) A possible chromosomal abnormality C) Facial paralysis D) Prematurity
Answer: A Explanation: A) The top of the ear (pinna) is parallel to the outer and inner canthus of the eye in the normal newborn. B) Low-set ears could indicate a chromosomal abnormality. C) This ear position is not indicative of facial paralysis. D) This ear position is not indicative of prematurity. Page Ref: 678
17) The mother of a 16-week-old infant is concerned because she cannot feel the posterior fontanelle on her infant. Which response by the nurse would be most appropriate? A) "It is normal for the posterior fontanelle to close by 8 to 12 weeks after birth." B) "Bring your infant to the clinic immediately." C) "This is due to overriding of the cranial bones during labor." D) "Your baby must be dehydrated."
Answer: A Explanation: A) This is a normal finding at 16 weeks. The posterior fontanelle closes within 8 to 12 weeks. B) There is no reason to bring the infant to the clinic. C) Overriding of the cranial bones is referred to as molding, and diminishes within a few days following birth. D) Fontanelles can be depressed when the infant is dehydrated. Page Ref: 675
33) The nurse is answering phone calls at the pediatric clinic. Which call should the nurse return first? A) Mother of a 2-week-old infant who doesn't make eye contact when talked to B) Father of a 1-week-old infant who sleeps through the noise of an older sibling C) Father of a 6-day-old infant who responds more to mother's voice than to father's voice D) Mother of a 3-week-old infant who has begun to suck on the fingers of the right hand
Answer: A Explanation: A) This is an abnormal finding. Orientation to the environment is determined by an ability to respond to cues given by others and by a natural ability to fix on and to follow a visual object horizontally and vertically. Inability or lack of response may indicate visual or auditory problems. B) Sleeping though noise is habituation, and is an expected behavior. C) The newborn can discriminate the individual characteristics of the human voice and is especially sensitive to sound levels within the normal conversation range. D) Self-consolatory behaviors such as sucking on fists, thumbs, or fingers are normal findings. Page Ref: 684
10) The nurse is preparing new parents for discharge with their newborn. The father asks the nurse why the baby's head is so pointed and puffy-looking. What is the best response by the nurse? A) "His head is molded from fitting through the birth canal. It will become more round." B) "We refer to that as 'cone head,' which is a temporary condition that goes away." C) "It might mean that your baby sustained brain damage during birth, and could have delays." D) "I think he looks just like you. Your head is much the same shape as your baby's."
Answer: A Explanation: A) This statement is accurate and directly answers the father's question. B) Although nursing staff might refer to a molded head as "cone head" and the shape is temporary, it is better to be more specific in explaining why the head is shaped as it is. In addition, this answer does not answer the "why" question posed by the father. C) A molded head shape does not indicate brain damage. Molding is normal and transient. D) Although this might be true, it is better to give a factual answer that does not imply that the father's head is abnormally shaped. This answer could be perceived as insulting. Page Ref: 674
11) The student nurse attempts to take a newborn's vital signs, but the newborn is crying. What nursing action would be appropriate? A) Place a gloved finger in the newborn's mouth. B) Take the vital signs. C) Wait until the newborn stops crying. D) Place a hot water bottle in the isolette.
Answer: A Explanation: A) Vital sign assessments are most accurate if the newborn is at rest, so measure pulse and respirations first if the baby is quiet. To soothe a crying baby, the nurse should place a moistened, unpowdered, gloved finger in the baby's mouth, and then complete the assessment while the baby suckles. B) Crying increases heart rate and respiratory rate, so vitals should not be taken when the newborn is crying. C) Assessment of vitals needs to be done at regularly timed intervals, so waiting until the newborn stops crying might cause too long a delay. D) A hot water bottle should not be placed next to the newborn because of the risk for burns. Page Ref: 678
30) 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? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) "The behavioral assessment should be done as soon after birth as possible." B) "The behavioral assessment can be performed without input from parents." C) "The behavioral assessment might be incomplete in a 1-hour home visit." D) "The behavioral assessment includes orientation and motor activity." E) "The behavioral assessment can detect neurological impairments."
Answer: A, B Explanation: A) Because the first few days after birth are a period of behavioral disorganization, the complete assessment should be done on the third day after birth. B) Parental input is required. It provides a way for the healthcare provider, in conjunction with the parents (primary caregivers), to identify and understand the individual newborn's states, temperament, capabilities, and individual behavior patterns. C) A full behavioral assessment includes the nurse observing the newborn's sleep-wake patterns, which is not likely to take place in a 1-hour home visit. D) Orientation to visual and auditory clues and motor activity are portions of the behavioral assessment. E) The behavioral assessment can detect neurological impairments. Page Ref: 684
27) Which of the following are important behaviors to assess in the neurologic assessment? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) State of alertness B) Active posture C) Quality of muscle tone D) Cry E) Motor activity
Answer: A, C, D, E Explanation: A) Important behaviors to assess are the state of alertness, resting posture, cry, and quality of muscle tone and motor activity. B) Resting posture is assessed, not active posture. C) Important behaviors to assess are the state of alertness, resting posture, cry, and quality of muscle tone and motor activity. D) Important behaviors to assess are the state of alertness, resting posture, cry, and quality of muscle tone and motor activity. E) Important behaviors to assess are the state of alertness, resting posture, cry, and quality of muscle tone and motor activity. Page Ref: 683
20) 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? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) The fontanelles can swell with crying. B) The fontanelles might be depressed. C) The fontanelles can pulsate with the heartbeat. D) The fontanelles might bulge. E) The fontanelles can swell when stool is passed.
Answer: A, C, E Explanation: A) Newborn fontanelles can swell when the newborn cries. B) Depressed fontanelles indicate dehydration. C) Newborn fontanelles can pulsate with the heartbeat. D) Bulging fontanelles signify increased intracranial pressure. E) Newborn fontanelles can swell when the newborn passes a stool. Page Ref: 688
34) The newborn's cry should have which of the following characteristics? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Medium pitch B) Shrillness C) Strength D) High pitch E) Lusty
Answer: A, C, E Explanation: A) The newborn's cry should be strong, lusty, and of medium pitch. B) A high-pitched, shrill cry is abnormal and may indicate neurologic disorders or hypoglycemia. C) The newborn's cry should be strong, lusty, and of medium pitch. D) A high-pitched, shrill cry is abnormal and may indicate neurologic disorders or hypoglycemia. E) The newborn's cry should be strong, lusty, and of medium pitch. Page Ref: 686
3) A new mother is concerned about a mass on the newborn's head. The nurse assesses this to be a cephalohematoma based on which characteristics? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) The mass appeared on the second day after birth. B) The mass appears larger when the newborn cries. C) The head appears asymmetrical. D) The mass appears on only one side of the head. E) The mass overrides the suture line.
Answer: A, D Explanation: A) A cephalohematoma is a collection of blood resulting from ruptured blood vessels between the surface of a cranial bone and the periosteal membrane. These areas emerge as defined hematomas between the first and second days. B) A cephalohematoma does not increase in size when the newborn cries. C) Molding causes the head to appear asymmetrical because of the overriding of cranial bones during labor and birth. D) Cephalohematomas can be unilateral or bilateral, but do not cross the suture lines. E) Cephalohematomas can be unilateral or bilateral, but do not cross the suture lines. Page Ref: 675
19) The nurse suspects clubfoot in the newborn and assesses for the condition by doing which of the following? A) Adducting the foot and listening for a click. B) Moving the foot to midline and determining resistance. C) Extending the foot and observing for pain. D) Stimulating the sole of the foot.
Answer: B Explanation: A) Adducting the foot and listening for a click is not a typical assessment. B) Clubfoot is suspected when the foot does not turn to a midline position or align readily. C) Extending the foot and observing for pain does not confirm or rule out clubfoot. D) Stimulating the sole of the foot elicits the plantar grasp reflex, and is not an appropriate assessment for clubfoot. Page Ref: 682
29) 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 doesn't turn her head and suck like the older two children did. Why?" What is the best response by the nurse? A) "Every baby is different. This is just one variation of normal that we see on a regular basis." B) "This baby might not have a rooting or sucking reflex because she is premature." C) "When she is wide awake and alert, she will probably root and suck even if she is early." D) "She might be too tired from the birthing process and need a couple of days to recover."
Answer: B Explanation: A) Although each baby is unique and different from siblings, this response is not accurate. B) Preterm babies may have suppressed or absent root and suck reflexes. C) This statement is true of term infants, but this infant is preterm. D) Although birth is stressful even to term newborns, and some require a day or two of recovery to become fully alert, this infant is preterm. Page Ref: 691
13) The nurse is completing the gestational age assessment on a newborn while in the mother's postpartum room. During the assessment, the mother asks what aspects of the baby are being checked. What is the nurse's best response? A) "I'm checking to make sure the baby has all of its parts." B) "This assessment looks at both physical aspects and the nervous system." C) "This assessment checks the baby's brain and nerve function." D) "Don't worry. We perform this check on all the babies."
Answer: B Explanation: A) Clinical gestational age assessment tools have two components: external physical characteristics and neurologic or neuromuscular development evaluations. B) Clinical gestational age assessment tools have two components: external physical characteristics and neurologic or neuromuscular development evaluations. C) Clinical gestational age assessment tools have two components: external physical characteristics and neurologic or neuromuscular development evaluations. D) Nurses must always use therapeutic communication and giving a "don't worry" answer dismisses the client's question or concern. Page Ref: 659
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? A) Lanugo mainly gone, little vernix across the body B) Prominent clitoris, enlarging minora, anus patent C) Full areola, 5 to 10 mm bud, pinkish-brown in color D) Skin opaque, cracking at wrists and ankles, no vessels visible
Answer: B Explanation: A) Lanugo and vernix disappear as the infant approaches term. B) At 30 to 32 weeks' gestation, the clitoris is prominent, and the labia majora are small and widely separated. As gestational age increases, the labia majora increase in size. At 36 to 40 weeks, they nearly cover the clitoris. At 40 weeks and beyond, the labia majora cover the labia minora and clitoris. C) Areolas develop greater size with advancing gestational age. D) The skin of a preterm infant is translucent, and vessels are visible through the skin. Page Ref: 664
24) The nurse determines the gestational age of an infant to be 40 weeks. Which characteristics are most likely to be observed? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Lanugo abundant over shoulders and back B) Plantar creases over entire sole C) Pinna of ear springs back slowly when folded. D) Vernix well distributed over entire body E) Testes are pendulous, and the scrotum has deep rugae
Answer: B, E Explanation: A) Vernix and lanugo both disappear as the infant reaches term. B) Sole (plantar) creases are reliable indicators of gestational age in the first 12 hours of life. C) The pinna's springing back slowly indicates prematurity. By term, the newborn's pinna is firm, stands away from the head, and springs back quickly from the folding. D) Vernix and lanugo both disappear as the infant reaches term. E) By term, the testes are generally in the lower scrotum, which is pendulous and covered with rugae. Page Ref: 661, 663
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? A) Notify the physician. B) Elevate the newborn's head. C) Document the findings in the chart. D) Assess for hypothermia immediately.
Answer: C Explanation: A) A physician would be notified only if findings were abnormal. B) There is no indication that the newborn's head should be elevated. C) Documentation is the appropriate first step. The average circumference of the head at birth is 32 to 37 cm, and average chest circumference ranges from 30 to 35 cm. D) None of the findings indicates hypothermia. No data on temperature are given. Page Ref: 669
22)Approximately what percentage of the newborn's body weight is water? A) 5% to 10% B) 90% to 95% C) 70% to 75% D) 50% to 60%
Answer: C Explanation: A) During the initial newborn period, term newborns have a physiologic weight loss of about 5% to 10% because fluid shifts. B) Approximately 70% to 75% of the newborn's body weight is water. C) Approximately 70% to 75% of the newborn's body weight is water. D) Approximately 70% to 75% of the newborn's body weight is water. Page Ref: 668
4) The nurse is using the New Ballard Score to assess the gestational age of a newborn delivered 4 hours ago. The infant's gestational age is 33 weeks based on early ultrasound and last menstrual period. The nurse expects the infant to exhibit which of the following? A) Full sole creases, nails extending beyond the fingertips, scarf sign showing the elbow beyond the midline B) Testes located in the upper scrotum, rugae covering the scrotum, vernix covering the entire body C) Ear cartilage folded over, lanugo present over much of the body, slow recoil time D) 1 cm breast bud, peeling skin and veins not visible, rapid recoil of legs and arms to extension
Answer: C Explanation: A) Full sole creases and nails beyond the fingertips are seen in term infants; a scarf sign beyond the midline is characteristic of a preterm infant. B) Testes in the upper scrotum and rugae-covered scrotum are seen in term infants. Vernix covering the body is an indication of a preterm infant. C) Ear cartilage folded over, lanugo present over much of the body, and slow recoil time are all characteristics of a preterm infant. D) 1 cm breast bud, peeling skin, the presence of adipose tissue so that veins are not visible, and rapid recoil of the legs and arms are all indications of term or post-term infants. Page Ref: 661
15) The nurse is teaching a class on infant care to new parents. Which statement by a parent indicates that additional teaching is needed? A) "The white spots on my baby's nose are called milia, and are harmless." B) "The whitish cheeselike substance in the creases is vernix, and will be absorbed." C) "The red spots with a white center on my baby are abnormal acne." D) "Jaundice is a yellowish discoloration of skin that if noticed on the 1st day of life should be reported to the physician."
Answer: C Explanation: A) Milia are exposed sebaceous glands, and appear as white spots, often across the nose. B) Disappearance of the protective vernix caseosa promotes skin desquamation. C) Red spots with white or yellow centers are erythema toxicum. The peak incidence is at 24 to 48 hours of life. The condition rarely presents at birth or after 5 days of life. The cause is unknown, and no treatment is necessary. D) Jaundice is a yellowish discoloration of skin and mucous membranes. Any jaundice noted before 24 hours of age should be reported to the physician or nurse practitioner. Page Ref: 672
16) 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? A) Nevus vasculosus B) Nevus flammeus C) Telangiectatic nevi D) A Mongolian spot
Answer: C Explanation: A) Nevus vasculosus is a strawberry hemangioma. B) Nevus flammeus is a port-wine stain hemangioma. C) Telangiectatic nevi (stork bites) appear as pale pink or red spots and are frequently found on the eyelids, nose, lower occipital bone, and nape of the neck. D) Congenital dermal melanocytosis (Mongolian blue spots) are macular areas of bluish black or gray-blue pigmentation commonly found on the dorsal area and the buttocks but may be anywhere on the body. Page Ref: 673
25) 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? A) Ortolani maneuver B) Palmar grasping reflex C) Clavicle D) Tonic neck reflex
Answer: C Explanation: A) Ortolani maneuver is an assessment technique that rules out the possibility of hip dislocation or hip instability. B) Palmar grasping reflex is elicited by stimulating the newborn's palm with a finger or object; the newborn grasps and holds the object or finger firmly enough to be lifted momentarily from the crib. C) When the Moro reflex is elicited, the newborn straightens arms and hands outward while the knees flex. Slowly the arms return to the chest, as in an embrace. If this response is not elicited, the nurse assesses the clavicle for a possible fracture. D) Tonic neck reflex (fencer position) is elicited when the newborn is supine and the head is turned to one side. In response, the extremities on the same side straighten, whereas on the opposite side they flex. Page Ref: 678
21) 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? A) The student nurse listens to bowel sounds, then assesses the head for skull consistency and size and tension of fontanelles. B) The student nurse checks for Ortolani's sign, then palpates the femoral pulse, then assesses respiratory rate. C) The student nurse determines skin color, then describes the shape of the chest and looks at structures and flexion of the feet. D) The student nurse counts the number of cord vessels, then assesses genitals, then sclera color and eyelids.
Answer: C Explanation: A) The head should be assessed before the bowel sounds. B) The respiratory rate should be assessed first, when the infant is at rest and undisturbed. C) Neonatal assessment proceeds in a head-to-toe fashion. D) The sclera and eye assessment should be done prior to assessing genitals. Page Ref: 668
28) 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? A) "My baby might open her arms wide and pull her legs up to her tummy if she is passing gas." B) "When I hold my baby upright with one of his feet on the floor, his feet will automatically remain still." C) "When I put my finger in the palm of my daughter's hand, she will curl her fingers and hold on." D) "I can get my baby to turn his head toward the right if I lift his right arm over his head."
Answer: C Explanation: A) This is the Moro or startle reflex, and occurs when the infant is startled by a sudden movement or a loud noise. B) Stepping reflex happens when a newborn who is held upright with one foot touching a flat surface puts one foot in front of the other and "walks." C) This is the Palmar grasp reflex and is elicited by stimulating the newborn's palm with a finger or object. D) This is the tonic neck reflex and is elicited when the newborn is supine and the head is turned to one side. In response, the extremities on the same side straighten, whereas on the opposite side they flex. Page Ref: 667
31) 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? A) "Some babies are easier to deal with than others." B) "We are lucky to have a baby with a calm disposition." C) "Our baby spends more time in the active alert phase." D) "Cuddliness is a social behavior that some babies have."
Answer: D Explanation: A) Calling the baby easy or difficult is a judgment that does not explain the baby's behavior. B) Describing the baby as calm is a judgment that does not explain the baby's behavior. C) The active alert phase of the sleep-awake cycle is characterized by motor activity. It does not explain the baby's behavior D) According to Brazelton Neonatal Behavioral Assessment Scale, cuddliness can be an indicator of personality. Page Ref: 684
26) The nurse is preparing to assess a newborn's neurological status. Which finding would require an immediate intervention? A) At rest, the infant has partially flexed arms and the legs drawn up to the abdomen. B) When the corner of the mouth is touched, the infant turns the head that direction. C) The infant blinks when the exam light is turned on over the face and body. D) The right arm is flaccid while the infant brings the left arm and fist upward to the head.
Answer: D Explanation: A) This is the normal resting posture of the infant. B) This is the rooting reflex, a normal finding in a newborn. C) Blinking in response to bright lights is an expected finding. D) Asymmetrical movement is not an expected finding, and could indicate neurological abnormality. Muscle tone should be symmetric and diminished muscle tone and flaccidity requires further evaluation. Page Ref: 683
