Newborn Assessment
A nurse is assessing the reflexes of a newborn. In checking for the Moro reflex, the nurse should perform which of the following? A.Make a loud noise such as clapping hands together over the newborn' s crib. B.Stimulate the pads of the newborn' s hands with stroking or massage. C.Stimulate the soles of the newborn's feet on the outer lateral surface of each foot. D.Hold the newborn in a semisitting position, then allow the newborn's head and trunk to fall backward
A. INCORRECT Clapping hands elicits the startle reflex. B. INCORRECT Stimulating the pads of the newborn's hands elicits the grasp reflex. C. INCORRECT Stimulating the outer lateral portion of the newborn's soles elicits Babinski's reflex. D. CORRECT The Moro reflex is elicited by holding the newborn in a semi-sitting position and then allowing the head and trunk to fall backward
4. A nurse is completing an assessment. Which of the following data indicate the newborn is adapting to extrauterine life? (Select all that apply.) A. Expiratory grunting B. Inspiratory nasal flaring C. Apnea for 10-second periods D. Obligatory nose breathing E. Crackles and wheezing
A. INCORRECT Expiratory grunting is a manifestation of respiratory distress. B. INCORRECT Nasal flaring is a manifestation of respiratory distress. C. CORRECT Periods of apnea lasting less than 15 seconds are an expected finding. D.CORRECT Newborns are obligatory nose breathers. E. INCORRECT Crackles and wheezing are symptoms of fluid or infection in the lungs
A nurse is preparing to bathe a newborn and observes a bluish marking across the newborn's lower back. A. The nurse should understand that this mark is frequently seen in newborns who have dark skin. B. a finding indicating hyperbilirubinemia. C. a forceps mark from an operative delivery. D. related to prolonged birth or trauma during delivery
A.CORRECT Mongolian spots are commonly found over the lumbosacral area of newborns who have dark skin and are of African American, Asian, or Native American origin. B.INCORRECT Hyperbilirubinemia would present as jaundice. C.INCORRECT Forceps marks would most likely present as a cephalohematoma. D.INCORRECT Birth trauma would present as ecchymosis
A nurse is completing a newborn assessment and observes small white nodules on the roof of the newborn's mouth. This finding is a characteristic of which of the following conditions? A. Mongolian spots B. Milia spots C. Erythema toxicum D. Epstein's pearls
A.INCORRECT Mongolian spots are dark areas observed in dark-skinned newborns. B.INCORRECT Milia are small white bumps that occur on the nose due to clogged sebaceous glands. C.INCORRECT Erythema toxicum is a transient maculopapular rash seen in newborns. D.CORRECT Epstein's pearls are small white nodules that appear on the roof of a newborn's mouth.
A nurse is caring for a newborn who was born at 38 weeks of gestation, weighs 3,200 g, and is in the 60th percentile for weight. Based on the weight and gestational age, the nurse should classify this neonate as: A. low birth weight. B. appropriate for gestational age. C. small for gestational age. D. large for gestational age.
A.INCORRECT A newborn who has a low birth weight would weigh less than 2,500 g. B. CORRECT This newborn is classified as appropriate for gestational age because the weight is between the 10th and 90th percentile. C. INCORRECT A newborn who is small for gestational age would weigh below the 10th percentile. D. INCORRECT A newborn who is large for gestational age would weigh above the 90th percentile
A nurse in the nursery is admitting a newborn 2 hr following birth. What nursing actions should the nurse use to evaluate newborn physical development? ●Describe at least three tools for assessment. ●Describe four reflex responses present at birth and how they are elicited. ●Describe newborn heart rate and how it is assessed
● Assessment tools: Brief initial systems assessment 1. Gestational age assessment - Physical measurements and New Ballard Scale 2. Vital signs 3. Head-to-toe physical assessment ● Reflexes 1. Sucking and rooting - Turns head to side that is touched and begins to suck when cheek or edge of mouth is stroked. 2. Palmar grasp - Grasps object when placed in palm. 3. Plantar grasp - Toes curl downward when sole of the foot is touched. 4. Moro - Arms and legs symmetrically extend and then abduct while fingers spread to form a "C" when infant's head and trunk are allowed to fall backward to an angle of at least 30 5. Tonic neck (fencer position) - Extends arm and leg on same side when head is turned to that side, and flexes arm and leg of opposite side. 6. Babinski's - Toes fan upward and out when outer edge of sole of foot is stroked, moving up toward toes. 7. Stepping - Makes stepping movements when held upright with feet touching flat surface. ● Heart rate 100 to 160/min with brief fluctuations above and below, depending on activity level. When newborn is sleeping, place pediatric stethoscope head on fourth or fifth intercostal space at the left midclavicular line over apex of the heart. Listen for a full minute. Note any murmurs.
