Ch. 28 Nursing Assessment of the Newborn

9) The nurse assesses four newborns. Which of the following assessment findings would place a newborn at risk for developing physiologic jaundice? 1. Cephalohematoma 2. Mongolian spots 3. Telangiectatic nevi 4. Molding

Answer: 1 Explanation: 1. 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.

24) What condition is due to poor peripheral circulation? 1. Acrocyanosis 2. Mottling 3. Harlequin sign 4. Jaundice

Answer: 1 Explanation: 1. 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.

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? 1. Arm recoil 2. Square window sign 3. Scarf sign 4. Popliteal angle

Answer: 1 Explanation: 1. 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.

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? 1. Brazelton Neonatal Behavioral Assessment Scale 2. New Ballard Score 3. Dubowitz gestational age scale 4. Ortolani maneuver

Answer: 1 Explanation: 1. 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.

19) 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? 1. Caput succedaneum 2. Cephalohematoma 3. Molding 4. Depressed fontanelles

Answer: 1 Explanation: 1. Caput succedaneum is a localized, easily identifiable soft area of the scalp, generally resulting from a long and difficult labor or vacuum extraction.

2) Before the nurse begins to dry off the newborn after birth, which assessment finding should the nurse document to ensure an accurate gestational rating on the Ballard gestational assessment tool? 1. Amount and area of vernix coverage 2. Creases on the sole 3. Size of the areola 4. Body surface temperature

Answer: 1 Explanation: 1. 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.

6) The nurse is making an initial assessment of the newborn. Which of the following data would be considered normal? 1. Chest circumference 31.5 cm, head circumference 33.5 cm 2. Chest circumference 30 cm, head circumference 29 cm 3. Chest circumference 38 cm, head circumference 31.5 cm 4. Chest circumference 32.5 cm, head circumference 36 cm

Answer: 1 Explanation: 1. 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.

40) 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? 1. "Your baby will respond to you the most if you look directly into his eyes and talk to him." 2. "Each baby is different. Don't try to compare your infant's behavior with 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 her during your pregnancy."

Answer: 1 Explanation: 1. The parents' visual (en face) and auditory (soft, continuous voice) presence stimulates their infant to orient to them.

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? 1. A normal position 2. A possible chromosomal abnormality 3. Facial paralysis 4. Prematurity

Answer: 1 Explanation: 1. The top of the ear (pinna) is parallel to the outer and inner canthus of the eye in the normal newborn.

18) The mother of a 16-week-old infant calls the clinic concerned because she cannot feel the posterior fontanelle on her infant. Which response by the nurse would be most appropriate? 1. "It is normal for the posterior fontanelle to close by 8 to 12 weeks after birth." 2. "Bring your infant to the clinic immediately." 3. "This is due to overriding of the cranial bones during labor." 4. "Your baby must be dehydrated."

Answer: 1 Explanation: 1. This is a normal finding at 16 weeks. The posterior fontanelle closes within 8 to 12 weeks.

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? 1. "His head is molded from fitting through the birth canal. It will become more round." 2. "We refer to that as 'cone head,' which is a temporary condition that goes away." 3. "It might mean that your baby sustained brain damage during birth, and could have delays." 4. "I think he looks just like you. Your head is much the same shape as your baby's."

Answer: 1 Explanation: 1. This statement is accurate and directly answers the father's question.

11) The student nurse attempts to take a newborn's vital signs, 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. 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.

36) 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. 1. "The behavioral assessment should be done as soon after birth as possible." 2. "The behavioral assessment can be performed without input from parents." 3. "The behavioral assessment might be incomplete in a 1-hour home visit." 4. "The behavioral assessment includes orientation and motor activity." 5. "The behavioral assessment can detect neurological impairments."

Answer: 1, 2 Explanation: 1. 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. 2. 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.

39) The nurse is explaining to a new mother that the newborn behavioral assessment includes which of the following? Note: Credit will be given only for all correct choices and for no incorrect choices. Select all that apply. 1. Habituation 2. Motor activity 3. Self-quieting activity 4. Cuddliness 5. Reflexes

Answer: 1, 2, 3, 4 Explanation: 1. Habituation is the newborn's ability to diminish or shut down innate responses to specific stimuli. 2. The newborn's motor tone is assessed in the most characteristic state of responsiveness. 3. Assessment is based on how often, how quickly, and how effectively newborns can use their resources to quiet and console themselves when upset or distressed. 4. Cuddliness encompasses the infant's need for and response to being held.

16) The nurse is assessing the gestational age of a 1-hour-old newborn. Which physical characteristics does the nurse assess? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Sole creases 2. Amount of breast tissue 3. Amount of lanugo 4. Reflexes 5. Testicular descent

Answer: 1, 2, 3, 5 Explanation: 1. Clinical gestational age assessment tools have two components: external physical characteristics and neurologic or neuromuscular development evaluations. Physical characteristics generally include sole creases, amount of breast tissue, amount of lanugo, cartilaginous development of the ear, testicular descent, and scrotal rugae or labial development.

30) When doing a neurologic assessment of a newborn, what would the nurse recognize? Select all that apply. 1. Muscle tone is assessed by moving various parts of the newborn's body while the newborn's head remains in a neutral position. 2. The newborn is somewhat hypertonic. 3. Muscle tone should be symmetrical. 4. Shortly after birth, the infant is flaccid at rest. 5. Diminished muscle tone requires further evaluation.

Answer: 1, 2, 3, 5 Explanation: 1. Moving various parts of the newborn's body while the newborn's head remains in a neutral position is the correct way to assess muscle tone. 2. The newborn will resist the examiner's attempts to extend the elbow and knee joints. 3. Muscle tone should be symmetrical. 5. If decreased muscle tone is noted, further evaluation is necessary.

29) Which of the following are important behaviors to assess in the neurologic assessment? Select all that apply. 1. State of alertness 2. Active posture 3. Quality of muscle tone 4. Cry 5. Motor activity

Answer: 1, 3, 4, 5 Explanation: Important behaviors to assess are the state of alertness, resting posture, cry, and quality of muscle tone and motor activity.

33) 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? 1. 2 months 2. 2 weeks 3. 1 year 4. 4 months

Answer: 4 Explanation: 4. The newborn might be demonstrating transient strabismus that is caused by poor neuromuscular control of the eye muscles. This will gradually regress in 3 to 4 months.

21) 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. 1. The fontanelles can swell with crying. 2. The fontanelles might be depressed. 3. The fontanelles can pulsate with the heartbeat. 4. The fontanelles might bulge. 5. The fontanelles can swell when stool is passed.

Answer: 1, 3, 5 Explanation: 1. Newborn fontanelles can swell when the newborn cries. 3. Newborn fontanelles can pulsate with the heartbeat. 5. Newborn fontanelles can swell when the newborn passes a stool.

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. 1. The mass appeared on the second day after birth. 2. The mass appears larger when the newborn cries. 3. The head appears asymmetrical. 4. The mass appears on only one side of the head. 5. The mass overrides the suture line.

Answer: 1, 4 Explanation: 1. 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. 4. Cephalohematomas can be unilateral or bilateral, but do not cross the suture lines.

38) The parents are asking the nurse about their newborn's behavior. The nurse begins to teach the parents about their newborn and involve them in their baby's care. What are these interventions directed at promoting to the parents? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Identification of responses or activities that best meet the special needs of their newborn. 2. Ability to evaluate the neurologic capacity of their newborn. 3. Understanding that the baby's temperament will be the same as their own. 4. Positive attachment experiences. 5. Understanding of the newborn's various behaviors.

Answer: 1, 4, 5 Explanation: 1. Families learn which responses, interventions, or activities best meet the special needs of their newborn, and this understanding fosters positive attachment experiences.

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? 1. Lanugo mainly gone, little vernix across the body 2. Prominent clitoris, enlarging minora, anus patent 3. Full areola, 5 to 10 mm bud, pinkish-brown in color 4. Skin opaque, cracking at wrists and ankles, no vessels visible

Answer: 2 Explanation: 2. 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.

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? 1. "I'm checking to make sure the baby has all of its parts." 2. "This assessment looks at both physical aspects and the nervous system." 3. "This assessment checks the baby's brain and nerve function." 4. "Don't worry. We perform this check on all the babies."

Answer: 2 Explanation: 2. Clinical gestational age assessment tools have two components: external physical characteristics and neurologic or neuromuscular development evaluations.

20) The nurse suspects clubfoot in the newborn and assesses for the condition by doing which of the following? 1. Adducting the foot and listening for a click. 2. Moving the foot to midline and determining resistance. 3. Extending the foot and observing for pain. 4. Stimulating the sole of the foot.

Answer: 2 Explanation: 2. Clubfoot is suspected when the foot does not turn to a midline position or align readily.

32) 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 his head and suck like the older two children did. Why?" What is the best response by the nurse? 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 might be too tired from the birthing process and need a couple of days to recover."

Answer: 2 Explanation: 2. Preterm babies may have suppressed or absent root and suck reflexes.

35) When assessing a full-term newborn, the nurse notes tremorlike movements. The nurse is aware that further evaluation is indicated to rule out which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Hyperglycemia 2. Hypoglycemia 3. Hypocalcemia 4. Substance withdrawal 5. Neurologic damage

Answer: 2, 3, 4, 5 Explanation: 2. Tremors or jitteriness (tremorlike movements) in the full-term newborn must be evaluated to differentiate the tremors from convulsions. Tremors may be related to hypoglycemia, hypocalcemia, or substance withdrawal.

25) 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. 1. Lanugo abundant over shoulders and back 2. Plantar creases over entire sole 3. Pinna of ear springs back slowly when folded. 4. Vernix well distributed over entire body 5. Testes are pendulous, and the scrotum has deep rugae

Answer: 2, 5 Explanation: 2. Sole (plantar) creases are reliable indicators of gestational age in the first 12 hours of life. 5. By term, the testes are generally in the lower scrotum, which is pendulous and covered with rugae.

23) Approximately what percentage of the newborn's body weight is water? 1. 5% to 10% 2. 90% to 95% 3. 70% to 75% 4. 50% to 60%

Answer: 3 Explanation: 3. Approximately 70% to 75% of the newborn's body weight is water.

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? 1. Notify the physician. 2. Elevate the newborn's head. 3. Document the findings in the chart. 4. Assess for hypothermia immediately.

Answer: 3 Explanation: 3. 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.

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? 1. Full sole creases, nails extending beyond the fingertips, scarf sign showing the elbow beyond the midline 2. Testes located in the upper scrotum, rugae covering the scrotum, vernix covering the entire body 3. Ear cartilage folded over, lanugo present over much of the body, slow recoil time 4. 1 cm breast bud, peeling skin and veins not visible, rapid recoil of legs and arms to extension

Answer: 3 Explanation: 3. Ear cartilage folded over, lanugo present over much of the body, and slow recoil time are all characteristics of a preterm infant.

22) 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? 1. The student nurse listens to bowel sounds then assesses the head for skull consistency and size and tension of fontanelles. 2. The student nurse checks for Ortolani's sign, then palpates the femoral pulse, then assesses respiratory rate. 3. The student nurse determines skin color, then describes the shape of the chest and looks at structures and flexion of the feet. 4. The student nurse counts the number of cord vessels, then assesses genitals, then sclera color and eyelids.

Answer: 3 Explanation: 3. Neonatal assessment proceeds in a head-to-toe fashion.

15) The nurse is teaching a class on infant care to new parents. Which statement by a parent indicates that additional teaching is needed? 1. "The white spots on my baby's nose are called milia, and are harmless." 2. "The whitish cheeselike substance in the creases is vernix, and will be absorbed." 3. "The red spots with a white center on my baby are abnormal acne." 4. "Jaundice is a yellowish discoloration of skin that if noticed on the 1st day of life should be reported to the physician."

Answer: 3 Explanation: 3. 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.

17) 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? 1. Nevus vasculosus 2. Nevus flammeus 3. Telangiectatic nevi 4. A Mongolian spot

Answer: 3 Explanation: 3. 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.

31) 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? 1. "My baby might open her arms wide and pull her legs up to her tummy if she is passing gas." 2. "When I hold my baby upright with one of his feet on the floor, his feet will automatically remain still. 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 his head toward the right if I lift his right arm over his head."

Answer: 3 Explanation: 3. This is the Palmar grasp reflex and is elicited by stimulating the newborn's palm with a finger or object.

27) 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? 1. Ortolani maneuver 2. Palmar grasping reflex 3. Clavicle 4. Tonic neck reflex

Answer: 3 Explanation: 3. 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.

26) A breastfeeding mother calls the pediatric clinic concerned about her 4-day-old baby's failure to gain weight. She states that the infant has lost several ounces since birth. The most appropriate response by the nurse would be which of the following? Select all that apply. 1. "Newborns tend to lose about 5% to 10% of their birth weight because of failure to give adequate supplements when breastfeeding." 2. "Newborns grow approximately 1 inch a month in the first 6 months. You will need to increase feedings to compensate for the growth spurt." 3. "Newborns have an initial weight loss in the first 3 to 4 days. Your baby's weight loss is normal." 4. "Newborns lose a lot of heat, so make sure you keep the baby's formula warm when you supplement the breast milk." 5. "Keep the baby from getting chilled or too warm because that can contribute to weight loss."

Answer: 3, 5 Explanation: 3. Newborns have a physiological weight loss of 5% to 10% in the first 3 or 4 days. 5. Weight loss in the newborn can be caused by temperature elevation or consistent chilling.

37) 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 Explanation: 4. According to Brazelton Neonatal Behavioral Assessment Scale, cuddliness can be an indicator of personality.

28) 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 the legs drawn up to the abdomen. 2. When the corner of the mouth is touched, the infant turns the head that direction. 3. The infant blinks when the exam light is turned on over the face and body. 4. The right arm is flaccid while the infant brings the left arm and fist upward to the head.

Answer: 4 Explanation: 4. 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.

34) A mother notices that her newborn is able to sleep without waking even when in the nursery with other newborns crying. The mother asks whether her baby might have a hearing problem because her father wears hearing aids. What should the nurse explain? 1. Newborn risk factors associated with potential hearing loss do not include a family history of hearing loss. 2. Newborns cannot hear, due to mucus accumulated in the middle ear, which takes several days to drain. 3. Newborns who are asleep do not respond to loud noises that are not accompanied by vibrations. 4. Newborns in a noisy nursery are able to habituate to the sounds, and might not react unless a sound is sudden or much louder.

Answer: 4 Explanation: 4. Habituation is the newborn's ability to diminish or shut down innate responses to specific repeated stimuli.

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? 1. 2 months 2. 2 weeks 3. 1 year 4. 4 months

Answer: 4 Explanation: 4. Transient strabismus is caused by poor neuromuscular control of the eye muscles and gradually regresses in 3 to 4 months.