Chapter 24 Nursing Assessment of the Newborn

12) The nurse is teaching a group of new parents about their infants. The infants are all 4 weeks of age or less. Which statement should the nurse include? 1. "The baby will respond to you the most if you look directly into your baby's eyes and talk to him." 2. "Each baby is different. Don't try to compare your infant's behavior to any other child's 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 him during your pregnancy."

Answer: 1 Explanation: 1. Holding the baby en face and speaking softly obtains the most response from the baby, including eye contact, smiling, and vocalization.

3) The nurse is preparing new parents to be discharged with their newborn. The mother asks the nurse why the baby's eyelids are so swollen. The best response by the nurse is: 1. "Swollen eyelids can happen because of the pressure associated with birth; the swelling should resolve in a few days." 2. "Newborn babies cry a lot and, as with adults, crying can cause our eyelids to be swollen." 3. "It's likely that your baby is developing an infection of the eyelids; I'll report this to the physician." 4. "Swollen eyelids are uncommon in newborns and may be an indication of a more serious disorder; if this does not resolve in one week, you need to visit your pediatrician."

Answer: 1 Explanation: 1. The eyelids are usually edematous during the first few days of life because of the pressure associated with birth.

13) The nurse is answering phone calls at the pediatric clinic. Which call should the nurse return first? 1. 2-week-old infant who doesn't make eye contact when talked to 2. 1-week-old infant who sleeps through the noise of an older sibling 3. 6-day-old infant who responds more to mother's voice than to father's voice 4. 3-week-old infant who has begun to suck on the fingers of her right hand

Answer: 1 Explanation: 1. This is an abnormal finding. Infants who do not make eye contact when talked to could have an ophthalmic abnormality.

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

Answer: 1 Explanation: 1. To soothe a newborn during assessment or other procedures, place a gloved finger into the newborn's mouth.

8) The nurse is planning an educational session for maternal-child health unit nurses to cross-train them for providing home-based care after discharge. Which statements indicate that additional teaching is required? "The behavioral assessment (select all that apply): 1. "Should be done as soon after birth as possible." 2. "Can be performed without input from parents." 3. "May be incomplete in a one-hour home visit." 4. "Includes orientation and motor activity." 5. "May detect neurological anomalies."

Answer: 1, 2 Explanation: 1. The behavioral exam is not accurate until about the third day of life. Newborns have disorganized behavior in the first days after birth. 2. Parental input is required to fully understand the infant's behaviors that are not observed by the healthcare team.

15) The nurse is assessing the newborn's sleep-wake cycle in a dimly lit room. The mother asks what the nurse is looking for and the nurse states she is looking for behaviors that are categorized by (select all that apply): 1. Cuddliness or social behaviors 2. How long the newborn sleeps 3. How much noise it takes to wake the newborn 4. Self-quieting activity 5. Motor activity

Answer: 1, 4, 5 Explanation: 1. This is one of the behaviors that are categorized by the sleep-wake cycle. 4. This is one of the behaviors that are categorized by the sleep-wake cycle. 5. This is one of the behaviors that are categorized by the sleep-wake cycle.

7) The nurse is working with a family that has just delivered their third child, at 33 weeks' gestation. The mother tells the nurse, "This baby doesn't turn his head and suck like the older two children did. Why?" The best response by the nurse is: 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 may be too tired from the birthing process and need a couple days to recover."

Answer: 2 2. Preterm babies often have a poor or absent root and suck reflex. They also might not have a swallow reflex and might require tube feedings temporarily.

14) The nurse is assessing a newborn. The parents are present. Which statement is best? 1. "Your infant was born with several reflexes. Some help her eat and protect her. I will show you what they look like." 2. "You will be most successful if you put your baby to breast when she has her eyes wide open and she is looking around." 3. "The muscle tone of your baby will increase as she gets older. You'll notice her head lagging less in a few weeks." 4. "The umbilical cord stump will dry up and fall off in about two weeks. There might be a spot of blood when it falls off."

Answer: 2 2. This statement is best because it is about the physical need of feeding. Infants feed best when they are in the active alert phase, characterized by quiet, eyes open, and looking calmly around.

16) The novice nurse is watching the nursery nurse perform an initial physical assessment on a newborn. The novice nurse asks, "What are some of the normal findings when performing the physical assessment?" Some of the normal findings are (select all that apply): 1. Low bridge of nose 2. Breech and cesarean newborns' heads are round 3. Weight is between 2500 to 4000 g 4. Eyes are edematous for first few days of life 5. Eyes have epicanthal folds

Answer: 2, 3, 4 2. This is a normal finding when performing a physical assessment on a newborn. 3. This is a normal finding when performing a physical assessment on a newborn. 4. This is a normal finding when performing a physical assessment on a newborn.

2) The nurse is observing a couple interacting with their 2-day-old child. Which of the mother's statements suggests a potentially abnormal finding in the newborn? 1. "She looks like she's a little bit cross-eyed." 2. "There is some white-colored drainage coming from her vagina." 3. "Her belly looks so round." 4. "She has some small white specks on the roof of her mouth."

Answer: 3 3. Abdominal distention is the first sign of many gastrointestinal abnormalities.

1) The nurse is using the New Ballard Score to assess the gestational age of a newborn delivered 4 hours ago. The infant is 33 weeks by early ultrasound and last menstrual period. The nurse expects the infant to exhibit: 1. Full sole creases, nails extending beyond the fingertips, scarf sign shows the elbow beyond the midline. 2. Testes located deep in the scrotum, rugae cover the scrotum, vernix covering the entire body. 3. Ear cartilage remains folded over, lanugo present over much of the body, and some flexion of arms and legs at rest. 4. 1 cm breast bud, peeling skin and veins not visible, rapid recoil of legs and arms to extension.

Answer: 3 3. All of these characteristics are indications of a preterm infant.

4) The nurse is assessing a newborn a few minutes after birth. The neonate has overlapping anterior fontanelles and suture lines. The best nursing action is to: 1. Contact the physician immediately. 2. Verify the presence of lanugo. 3. Document the findings. 4. Assess for rectal patency.

Answer: 3 3. Because overlapping fontanels and sutures are a common variation of normal, documenting the findings is appropriate.

6) The nurse is completing a newborn care class. The nurse knows that teaching has been effective if a new parent states: 1. "My baby may open her arms wide and pull her legs up to her tummy if she is passing gas." 2. "If my baby curls his toes downward when I stroke the sole of his foot, he is normal." 3. "When I put my finger in the palm of my daughter's hand, she will curl her fingers and hold on." 4. "I can get my baby to turn her head towards the right side if I lift her right arm over her head."

Answer: 3 3. This is the palmar grasp reflex. The plantar surface of the foot has a similar reflex.

10) The nurse is teaching a class to parents about the components of newborn behavioral assessment. Which parent's statement suggests that educational material has been accurately understood? 1. "My baby's ability to shut down his natural response to the sound of a rattle is considered a part of the variations assessment." 2. "Habituation includes an allover assessment of my baby's body tone." 3. "Observing my baby's frequency of alert status and peaks of excitement is part of the self-quieting activity component." 4. "Motor activity includes assessing my baby's overall tone when he's being handled."

Answer: 4 4. Assessment of motor activity includes assessing the infant's overall use of tone while the baby is being handled.

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

Answer: 4 4. Asymmetrical movement is not an expected finding and could indicate neurological abnormality. This should be reported to the physician immediately.

11) 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."

Answer: 4 4. The Brazelton Neonatal Behavioral Assessment Scale looks at habituation, orientation to animate or inanimate visual or auditory stimuli, motor activity, self-quieting, cuddliness or social behaviors, and variations of each of these categories.