Pretest newborn assessment
The nurse is assessing a newborn infant. Which assessment finding would indicate the need for immediate intervention? central cyanosis
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.
Which percentage of weight loss does the nurse anticipate for a newborn during the first week of life? 10%
It is normal for the newborn to lose up to 10% of birth weight during the first week of life. The nurse should reassure the parents this is usually regained in a period of 2 weeks as long as feeding goes well. Newborns may lose more than 5% of their birth weight without concern. A loss of 15dash-20% of the birth weight in the first week of life indicates a problem. The nurse should assess feeding patterns of the newborn and complete a health assessment. Findings should be reported to the healthcare provider.
The nurse is performing a newborn assessment to determine gestational age. Which assessment findings does the nurse expect for a full-term infant? Opaque skin Plantar creases on the anterior 2/3 of the newborns sole
Opaque skin and plantar creases on the anterior two thirds of the newborn's sole are indications of a term infant. A large amount of lanugo over the back and minimal ear cartilage are indications of a premature infant. The heart rate assessment is not part of the gestational age assessment. Next Question
During the initial exam, a newborn estimated at 40 weeks gestation weighs 7 lb 8 oz (3,550 g). Which classification is most appropriate for this newborn based on birth weight and gestational age? appropriate for gestational age
The appropriate for gestational age (AGA) infant falls between the 10th and the 90th percentiles for gestational age when birth weight and gestational age determination (Ballard assessment) are considered together. T
A preterm infant arrives in the nursery. Which initial assessments will the nurse make on this infant? 1. Gestational age determination 2. Core temperature readings 3. Sings of respiratory distress
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.
Which data would be considered normal during an initial nursing assessment of a term newborn? chest circumference 31.5 cm, head circumference 33.5
At birth, the circumference of the newborn's head is 32dash-37 cm. The average circumference of the chest is 32 cm and ranges from 30 to 35 cm. At birth, the circumference of the head is approximately 2 cm greater than the newborn's chest.
Which characteristics does the nurse anticipate when assessing a newborn infant born at 33 weeks gestation? Ear cartilage remains folded over, lanugo present over much of the body, some flexion of arms and legs at rest
Ear cartilage remains folded over, lanugo present over much of the body, and some flexion of arms and legs at rest are signs of a premature infant. Full sole creases, nails extending beyond fingertips, testes deep in rugae covered scrotum, 1-cm breast bud, peeling skin without visible veins, and rapid recoil of legs and arms are signs of a postterm infant. Next Question
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? 1. The newborn's weight falls below the 10th percentile 2. The newborn may have suppered from intrauterine growth restriction (IUGR)
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.
Which element will the nurse include when assessing the neuromuscular maturity of an infant who is 4 hours old? HEEL-TO HEAR EXTENSION
Neuromuscular assessment of the newborn includes heel-to-ear extension. Skin appearance, breast bud tissue and genitalia are parts of the physical assessment, not the neuromuscular assessment. Next Question
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? FULL TERM
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.
Question Help 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 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? Respirations 78 breaths/min
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 30dash-60 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 110dash-160 beats/min.
Which action is most appropriate if a newborn's anti-abduction bracelet accidently comes off? replace it according to policy
The nurse should regularly assess the newborn's anti-abduction bracelet. It is not uncommon to find a bracelet inside a blanket that has accidentally come off. If this occurs, the nurse should follow the agency policy for replacing it. The nurse would not notify security unless there was suspicion of newborn abduction. It is not advisable for the nurse to leave the bracelet off for security reasons. Unless agency policy requires completing an incident report, it is not reasonable to assume this would be an action required of the nurse. OK
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? NERUOMUSCULAR
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 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 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 conducting a gestational age assessment on a newborn. Which physical assessment finding would the nurse record during this assessment?
plantar creases present on anterior 2/3 of the sole Areas for assessment for physical maturity include lanugo, plantar creases, breast tissue, ears, and genitalia. Head-to-toe physical assessment includes examination of the umbilical cord, fontanelles, and the presence of milia. Next Question
