Chapter 30: Assessing Newborns and Infants
The student nurse reports that the breath sounds of an infant are loud and harsh. How should the nurse best respond? "This infant needs oxygen to ease his breathing." "Breath sounds in infants will be louder and harsher due to a thinner chest wall" "This is a sign of infection. The physician needs to be notified." "This is an indication of respiratory distress in infants."
"Breath sounds in infants will be louder and harsher due to a thinner chest wall"
A mother of a newborn expresses concern to the nurse that her baby's eyes appear blue but both she and the baby's father have brown eyes. How should the nurse respond to the mother's concern? "Do any grandparents on either side have blue eyes? "Don't worry as long as the pupil is normal in color." "I will perform a pupil test to be sure everything is normal." "Permanent eye color will appear about 9 months of age."
"Permanent eye color will appear about 9 months of age." Typically, the iris of the eye is blue in light-skinned infants and brown in dark-skinned infants. Permanent eye color develops around 9 months of age. The grandparents' eye color would not impact the infant's eye color at birth. Telling the mother not to worry does not answer the question or make the mother feel comfortable. There is nothing wrong with the infant's pupils, so a check is not necessary.
A mother brings her 2-month-old to the clinic for a well-baby check-up. The mother expresses concern that the infant is constantly sucking on their hand or any object they can get their hands on. What is the best response by the nurse? "This is a normal developmental activity for an infant." "Have you childproofed your home yet?" "Make sure you wash your infant's hands frequently, because they put them in their mouth." "You should use a pacifier to prevent the child from sucking on other things."
"This is a normal developmental activity for an infant." According to Freud's theory on psychosexual development, newborns and infants (birth to 18 months) are in the oral stage of development. According to Freud's theory, the erogenous zone is the mouth; in this stage the newborn/infant will suck, swallow, chew, and bite for pleasure and to explore their world. Telling the mother to use a pacifier does not answer the mother's concerns and it is a poor communication technique to tell the client what they should do. It is normal for an infant to put their hands in their mouth, so washing the baby's hands frequently is not necessary and may lead to abnormal dryness; infants' hands only need to be washed if their hands become contaminated with a foreign substance, an animal, or another child. Asking if the home has been childproofed yet does not answer the mother's concerns.
A new mother tells the nurse that the newborn has a small yellow lesion on the hard palate of the mouth and is worried about the baby's ability to suck properly. What should the nurse tell the mother about this finding? "This is common and will disappear within the first few weeks." "These are caused by improper sucking by the infant." "This is a congenital abnormality called cleft palate." "I will get an order to culture this for infection."
"This is common and will disappear within the first few weeks." This finding is common in newborns and is called an Epstein pearl. It is found on the hard palate and gums and presents as a small, yellow-white retention cyst that disappears within the first few weeks of life. Sucking tubercles are common in infants on the upper lip but do not occur from improper sucking. This is not an infection, thus no culture is needed. A cleft palate usually occurs together with a cleft lip. A cleft is a fissure, opening, or gap. It is the nonfusion of the body's natural structures that form before birth.
A nurse is providing care to a mother and her newborn (12 hours old). The nurse observes a yellowing tint of the newborn's skin. The mother asks, "Is it okay that my baby is yellow?" What is the best response by the nurse? "I would not worry about it. It will clear up in a few days without treatment." "This may be a pathological condition. I will need to notify the health care provider." "Yellow skin is common in newborns; it will clear up with ultraviolet light therapy." "This is normal for newborns; all newborns have a yellow tint."
"Yellow skin is common in newborns; it will clear up with ultraviolet light therapy." Yellow skin (jaundice) in newborns is common. It is due to immature liver function. Ultraviolet light (artificial or sunlight) will help lower bilirubin levels. Not all newborns have jaundice; if a newborn develops jaundice within 24 hours after birth it may indicate hemolytic disease, but the nurse would not alarm the client by stating this until further assessments were conducted. Telling the client not to worry about it is nontherapeutic communication (false reassurance). Until further assessments are completed, the nurse would not know if it will clear up on its own without treatment.
What should a nurse expect to hear when auscultating a newborn's heart sounds? Select all that apply. Loud Low-pitched Soft High-pitched Short duration
- Loud - High-pitched - Short duration
The nurse is assessing a 1-year-old infant who weighed 3.6 kg (8 lb) at birth. When the nurse prepares to weigh the infant, the nurse anticipates that this infant should weigh approximately 10.8 kg (24 lb). 12.7 kg (28 lb). 7.2 kg (16 lb). 9.07 kg (20 lb).
10.8 kg (24 lb). Deviation from the wide range of normal weights is abnormal. Compare differences by referencing the growth charts available at http://www.cdc.gov/growthcharts.
The anterior fontanelle of a neonate closes between 4 and 6 months. 7 and 11 months. 2 and 3 months. 12 and 18 months.
12 and 18 months. The anterior fontanelle usually measures 4 to 6 cm at birth and closes between 12 and 18 months.
A newborn appears to be in respiratory distress with a respiratory rate of 70 breaths/min, nasal flaring, and intercostal retractions. The newborn has a temperature of 37.2°C (98.9°F;) and a pulse rate of 190 beats/min. What is the normal range for a newborn's heart rate? 60-100 beats/min 100-110 beats/min 120-160 beats/min 160-190 beats/min
120-160 beats/min Apical pulse and respiratory rate should be measured for a full minute each with the infant at rest. Pulse range for the newborn is 120 to 160 beats/min.
A nurse obtains Apgar scores on a newborn at 1 minute after birth. When should the nurse perform the next Apgar score? every minute for 5 minutes 5 minutes 10 minutes 2 minutes
5 minutes Apgar scores are obtained at 1 minute after birth and again at 5 minutes after birth to determine the need for medical care. A score of 0 to 3 indicates a prompt need for resuscitation, 4 to 6 the newborn may need some assistance for breathing, and 7 to 10 the child is in excellent condition and no medical care is required.
A newborn is being assessed at 1 minute after birth. A score that indicates the newborn is adapting well to the extrauterine environment is in what range? 3 to 5 5 to 7 7 to 10 11 to 13
7 to 10 The Apgar score is one of the first newborn assessments the nurse makes. It is not used to guide resuscitation efforts but gives important clues about how well the newborn is adapting to life outside the womb. The newborn receives a score of 0 to 2 in each of 5 areas for a possible total score of 10. The score is calculated at 1 min and again at 5 min of life. Score of 7 to 10 indicates a vigorous newborn adapting well to the extrauterine environment. This makes the other options incorrect.
Which action by the nurse demonstrates the correct technique to elicit Ortolani's maneuver? Adduct the legs until the nurse's thumbs touch Spread the buttocks with gloved hands Assess the symmetry of the gluteal fold Abduct the legs and move the knees outward
Abduct the legs and move the knees outward The nurse should abduct the legs and move the knees outward to elicit Ortolani's maneuver. Barlow's maneuver involves adducting the legs until the thumbs of the nurse touch. Assessing the symmetry of the gluteal fold is done to look for hip dysplasia but is not a part of Ortolani's maneuver. The buttocks are spread with gloved hands to examine the anus.
A nurse assigns an Apgar score to a newborn baby at 5 minutes after delivery. Which parameter should the nurse recognize as an abnormal finding? Active movement of all four extremities Vigorous crying with flexed extremities Overall skin tone is pink Apical pulse is less than 100 beats per minute
Apical pulse is less than 100 beats per minute A newborn's heart rate ranges from 120 to 160 beats per minute until about 6 months of age. A heart rate less than 100 beats per minute is abnormal, and the nurse needs to further assess the newborn. Normal findings include the newborn crying with flexed extremities, displaying active movement, and having pink skin tone.
Which action by the nurse demonstrates the correct technique of assessing for the square window sign? Flex the elbows bilaterally up Bend wrist toward ventral forearm Flex thigh on top of the abdomen Lift the arm toward the opposite shoulder
Bend wrist toward ventral forearm To assess the square window sign, the nurse should bend the newborn's wrist towards the ventral forearm until resistance is met and the angle is measured. Flexing the thigh on top of the abdomen is used to test the popliteal angle. Flexing the elbows up bilaterally is done to test arm recoil. Lifting the arm across the chest towards the opposite shoulder until resistance is met is done to elicit the Scarf sign.
A nurse performs an Apgar assessment on a newborn at 1 minute with a score of 7 and at 5 minutes with a score of 10. What action should the nurse take? Document normal findings. Provide prompt resuscitation. Reassess in 5 minutes. Provide some assistance for breathing.
Document normal findings. Apgar is used immediately after birth at 1 minute and 5-minute intervals to determine if medical care is needed. A score of 7 to 10 means the newborn is in excellent condition. A score of 4 to 6 indicates a need for assistance with breathing. A score of 0 to 3 indicates a need for prompt resuscitation. Assistance for breathing or resuscitation is not required in this case because these are normal findings for a newborn. Reassessing in 5 minutes may be necessary if there are changes in the neonate's condition, but this is not the best action for the nurse to take at this time.
The nurse notes that a sleeping newborn's heart rate is 102 bpm. What action should the nurse take first? Document the heart rate Increase the temperature in the incubator Notify the health care provider Apply oxygen
Document the heart rate A pulse rate of 100 bpm when the infant is sleeping is considered normal and should be documented. There is no need to apply oxygen, notify the health care provider, or increase the temperature in the incubator.
A nurse assesses a newborn with bruising on the head. How should the nurse document this finding? Ecchymoses Lanugo Vernix caseosa Erythema toxicum
Ecchymoses Ecchymosis is bruising of the skin. The white, cheesy substance seen on the skin of the infant, especially in the folds of the skin, is vernix caseosa, which is normal in the newborn. Lanugo is the fine, downy hair that disappears after 2 weeks of life. Erythema toxicum is the rash seen in the first few days after the birth.
The nurse assesses the skin of a 2-week-old infant. For which finding should the nurse notify the health care provider? Telangiectatic nevi over the left shoulder Eight hyperpigmented macules over both legs Small birth mark on the back of the right upper leg Port-wine stain at the base of the neck
Eight hyperpigmented macules over both legs Hyperpigmented macules are considered Café au lait spots. If more than 6 are present, it may indicate neurofibromatosis and should be reported to the health care provider. A port-wine stain, telangiectatic nevi, and birth marks are considered normal newborn skin variations.
The nurse learns that a new mother was upset after hearing about being pregnant and did not look forward to the birth of the baby. On what should the nurse focus when assessing the mother and the baby? Physiological recovery Emotional attachment Infant sleeping behavior Mother's plan to return to work
Emotional attachment
While assessing a newborn infant, the nurse observes yellow-white retention cysts in the newborn's mouth. The nurse should explain to the infant's parents that these spots are usually indicative of thrush. allergic reactions. Epstein pearls. dehydration.
Epstein pearls. Epstein's pearls—small, yellow-white retention cysts on the hard palate and gums—are common in newborns and usually disappear in the first weeks of life.
Which action by the nurse demonstrates the correct technique of assessing for arm recoil? Bend wrist toward ventral forearm Flex thigh on top of the abdomen Lift the arm toward the opposite shoulder Flex the elbows up bilaterally
Flex the elbows up bilaterally Flexing the elbows up bilaterally is done to test arm recoil. Flexing the thigh on top of the abdomen is used to test the popliteal angle. To assess for the square window sign, the nurse should bend the newborn's wrist towards the ventral forearm until resistance is met and the angle is measured. Lifting the arm across the chest towards the opposite shoulder until resistance is met is done to elicit the Scarf sign.
A new mother wants to give her baby honey. The nurse tells her that it is potentially dangerous to do this. Why is this practice potentially dangerous? The baby cannot digest honey until 1 year of age Honey is too thick for the baby to swallow and could be a choking hazard Rates of honey allergies in infants are high Honey is a known reservoir for the botulism bacterium
Honey is a known reservoir for the botulism bacterium Honey should not be given to infants. It is a known reservoir for the bacterium that causes botulism. The spores that the bacteria produce make a toxin that can cause infant botulism, a serious form of food poisoning. The toxin affects the infant's neurologic system and can lead to death. There is no high rate of honey allergies in infants; the baby can digest honey, and honey is not too thick for the baby to swallow.
On assessing a newborn, a nurse observes a separation of the abdominal muscles. That nurse recognizes the underlying case of this condition is which of the following? Umbilical hernia Malnutrition and dehydration Pyloric stenosis Immature abdominal muscles
Immature abdominal muscles (separation of the abdominal muscles) is seen as a midline protrusion from the xiphoid to the umbilicus or pubis symphysis. This condition is secondary to immature abdominal muscles and usually has little significance. A scaphoid (boat-shaped; i.e., sunken with prominent rib cage) abdomen may result from malnutrition or dehydration. A distended abdomen may indicate pyloric stenosis. A bulge at the umbilicus suggests an umbilical hernia.
A nurse inspects the anus of a newborn. Which of the following findings should be referred immediately to a specialist? Perianal skin tags Passing of meconium Imperforate anus Pustules
Imperforate anus Imperforate anus (no anal opening) should be referred. The anal opening should be visible and moist. Perianal skin should be smooth and free of lesions. Perianal skin tags may be noted. No passage of meconium stool could indicate a lack of patency of anus or cystic fibrosis. Meconium is passed within 24 to 48 hours after birth. Pustules may indicate secondary infection of diaper rash.
A mother brings her 2-month-old infant to the health care facility with a high temperature. Which action by the nurse demonstrates the proper way to safely measure the rectal temperature in the baby? Bend the newborn's legs at the knees Lay the baby in prone position Insert the thermometer no more than 2 cm into the rectum Hold the thermometer in place for 1 minute
Insert the thermometer no more than 2 cm into the rectum The rectal temperature is most accurate. The nurse should insert the lubricated rectal thermometer no more than 2 cm into the rectum when taking the rectal temperature. The baby should be in the supine position and not in the prone position when assessing rectal temperature. The newborn's legs should be bent at the hip, not at the knees. Temperature registers in 3 to 5 minutes, not 1 minute, on a rectal thermometer.
A nurse assesses a newborn and finds fine, downy hair all over the newborn's skin. How should the nurse document this finding? Ecchymoses Lanugo Erythema toxicum Vernix caseosa
Lanugo Lanugo is the fine, downy hair that disappears after 2 weeks of life. The white, cheesy substance seen on the skin of the infant, especially in the folds of the skin, is vernix caseosa, which is normal in the newborn. Ecchymosis is bruising of the skin. Erythema toxicum is the rash seen in the first few days after the birth.
Which procedure demonstrates correct placement of a tape measure by a nurse when measuring the chest circumference of a 12-month-old infant? Nipple line At the xiphoid process Under the axilla Below the rib cage
Nipple line
The nurse is performing an eye assessment on a newborn and is unable to elicit a red reflex. What is the priority intervention that the nurse should do at this time? Nothing--newborns do not have a red reflex. Notify the physician. Although of no clinical significance, document the finding on the clinical record. Continue with the assessment.
Notify the physician. The inability to elicit a red reflex from a newborn can be clinically significant. The infant should be referred to a specialist. Absence of a red reflex can indicate congenital cataracts or neuroblastoma.
During examination of a newborn, the nurse presses her finger against the newborn's palm and the newborn grasps the finger. What reflex is the nurse eliciting from this action? Rooting Babinski Moro Palmar
Palmar The Babinski reflex is assessed by holding up the newborn's foot and stroking up the lateral edge and across the ball. A positive Babinski reflex is fanning of the toes. The rooting reflex in the baby occurs when the nurse touches the upper lip so that the newborn will move the head towards the stimulated area and open the mouth. The Moro or startle reflex occurs normally only in the first 4 months following birth. The palmar reflex is elicited by pressing the fingers against the palmar surface of the newborn's hands from the ulnar side.
A nurse assesses an 8-month-old infant and observes an irregular shape to the infant's head. What assessment should the nurse perform next? Head posture and control Palpate anterior fontanelle Movement of extremities Pupillary response to light
Palpate anterior fontanelle After observing an irregularly shaped head, the nurse should palpate for the anterior fontanelle because premature closure will cause the head to become irregular in shape. Then the nurse can perform further neurologic assessment of the infant to assess for deficits.
When assessing a newborn post vaginal delivery, the nurse observe bluish colored hands and feet. What is the nurse's priority action? Palpate the apical pulse at the 5th left intercostal space. Call the emergency response team immediately. Notify the healthcare provider to evaluate the newborn. Place the newborn under the radiant warmer.
Place the newborn under the radiant warmer. The first action of the nurse is to place the infant under the radiant warmer. The hands and feet of the newborn may appear blue at times (acrocyanosis), which is normal, especially when the newborn is cold. With warming, skin color should return to pink. If the infant does not respond with warming techniques (placing newborn under radiant heater or adding a layer of blankets), consider a congenital heart defect in the newborn. The nurse should auscultate, not palpate, the apical pulse at the 4th intercostal space. The remaining options are premature and should be implemented when assessment warrants such actions.
The mother of a newborn has struggled to effectively breastfeed her daughter. The mother has received instruction from a lactation specialist on proper breastfeeding techniques, but the baby will not latch on. She has decided to bottle feed the baby at least for now. Also, when assessing the infant's musculoskeletal system, the nurse found unequal gluteal folds and limited hip abduction. Which of the following should be the priority nursing conclusion? RC: Hip displacement RC: Failure to thrive Knowledge deficit Risk for Ineffective Breastfeeding
RC: Hip displacement The priority conclusion is that the infant is at risk for complications related to hip displacement, as the findings of unequal gluteal folds and limited hip abduction indicate. The problem related to breastfeeding does not appear to be an issue of knowledge deficit, as the mother has received proper instruction. Also, risk for ineffective breastfeeding would be an inaccurate diagnosis, as ineffective breastfeeding has already occurred. Because the baby has switched to bottle feeding, however, and because there are no other adverse indications related to the child's weight gain or nutritional status, there is no failure to thrive or risk of complications thereof.
To obtain the most accurate temperature on an infant, a nurse should use which method? Axillary Oral Skin Rectal
Rectal A rectal temperature is the most accurate method for obtaining a temperature on an infant. Oral temperatures are not recommended until childhood when the child can understand the concept of holding the thermometer in the mouth.
A nursery nurse is assessing the neurologic status of a newborn. What area would the nurse be assessing? Pain Weight and length Reflexes Ability to eat
Reflexes
The nurse begins the assessment of a 1-month-old baby. What should the nurse do first when weighing this client? Remove all clothing Hold the infant over the abdomen Place paper on the scale Ask the mother to hold the head to prevent movement
Remove all clothing An infant should be weighed naked. Paper is used when measuring length. The infant should not be held at the abdomen or the head when measuring body weight.
During examination of a newborn, the nurse touches the upper lip so that the newborn will move the head towards the stimulated area and open the mouth. What reflex is the nurse eliciting from this action? Sucking Plantar Rooting Palmar
Rooting The nurse is eliciting the rooting reflex in the baby. The sucking reflex is assessed by placing a nipple in the newborn's mouth. The plantar reflex is assessed by touching the ball of the newborn's foot so that the toes curl downwards tightly. The palmar reflex is elicited by pressing the fingers against the palmar surface of the newborn's hands from the ulnar side.
The nurse is performing a routine newborn assessment and gently strokes the cheek of the baby. The newborn turns toward the stroke and opens the mouth. What is this reflex called? Rooting reflex Babinski reflex Moro reflex Tonic neck reflex
Rooting reflex The rooting reflex is exhibited when the cheek is stroked and the newborn turns toward the stimulus and opens the mouth. This reflex disappears at 3 to 4 months, although it may persist longer. Absence indicates a neurological disorder.
A nurse assesses a newborn of African American descent and observes a bluish-pigmented area on the sacrum. The nurse recognizes this as what type of skin variation? Trauma from delivery Erythema toxicum Telangiectatic nevi Slate gray nevus
Slate gray nevus A bluish coloration of the skin on the sacral area is called a slate gray nevus and is common in infants of Asian, African American, Native American, and Mexican American descent. (Note: slate gray nevi were previously known as Mongolian spots.) Erythema toxicum consists of tiny bumps that are firm, yellowish, or white, and surrounded by a ring of redness. The rash usually appears on the baby's face, chest, arms, and legs. Telangiectatic nevi are flat, red birthmarks often called port wine stains. Trauma from delivery can be seen anywhere and manifest as any type of abnormality.
Which action by the nurse demonstrates the correct technique to assess the anus? Abduct the legs and move the knees outward Adduct the legs until the nurse's thumbs touch Assess the symmetry of the gluteal fold Spread the buttocks with gloved hands
Spread the buttocks with gloved hands
A group of students is preparing a class presentation on infant sleeping and Sudden Infant Death Syndrome. The presentation would include which of the following? Teach parents that it is okay for them to sleep with their infants occasionally Teach parents to use pillows for their infants Explain the importance of maintaining functioning smoke alarms on every floor and in every sleeping area of the home Teach parents about placing the baby on his back to sleep.
Teach parents about placing the baby on his back to sleep. Appropriate education topics involve teaching parents the importance of not sleeping with infants and safe sleep practices for infants, who are to always be placed on their backs to sleep, with no pillows or excessively soft bedding or toys in cribs. Smoke alarms have nothing to do with sleeping and Sudden Infant Death Syndrome.
A nurse midwife is making a well-baby visit for a 5-month-old infant. The nurse determines delayed development when which of the following is observed? The infant's respiratory rate is 40 breaths/min. The infant lacks head control. The infant shows a positive Babinski response. The infant seeks comfort from the parent.
The infant lacks head control. Infants should have head control by 4 months of age. If the infant lacks head control by 6 months, this may indicate cerebral palsy. A positive Babinski reflex (fanning of the toes) is normal up to 2 years in infants. The child seeking comfort from their parent indicates that trust versus mistrust has been achieved according to Erikson's psychosocial development theory. A respiratory rate of 40 breaths/min is normal in infants up to 12 months.
When performing an assessment of a 2-month-old infant, the nurse turns the baby's head to the side while the infant is supine. The arm and leg extend on the side to which the face is pointed. The contralateral arm and leg flex, forming the classic fencing position. What is the name of this reflex? Palmer grasp reflex Moro reflex Tonic neck reflex Rooting reflex
Tonic neck reflex When assessing the tonic neck reflex, turn the head of the supine infant to one side. The arm and leg extend on the side to which the face is pointed. The contralateral arm and leg flex, forming the classic fencer position. Repeat by turning the head to the other side--the position will reverse. This reflex is strongest at 2 months and disappears by 6 months. If still present at 9 months, it may indicate neurological damage.
What should a nurse keep in mind when palpating for the testes in a male infant? The right testicle is often larger than the left causing it to hang lower Often the left testicle cannot be palpated because it is smaller Touch or cold may pull the testicles back into the inguinal canal They must be milked because they are still in the inguinal canal
Touch or cold may pull the testicles back into the inguinal canal When palpating the testicles, the nurse must keep in mind the cremasteric reflex. This reflex pulls the testicles up into the inguinal canal and abdomen and is elicited in response to touch, cold, or emotional factors. If they can be milked into the scrotum form the inguinal canal, suspect physiologic cryptorchidism. The left testicle may hand lower than the right but they are the same size.
A nurse performs, measures, and documents the findings of the initial newborn assessment. Which data should the nurse recognize as an abnormal finding in the newborn? Chest circumference is 30 cm Weight of 2000 g Head circumference is 34 cm Length of 49 cm
Weight of 2000 g A weight of 2000 g in a newborn is an abnormal finding. The newborn usually weighs 2500 to 4000 g. The normal head circumference is 33 to 35.5 cm. The normal length of the newborn is 44 to 55 cm, and the chest circumference is 30 to 33 cm.
Normal breathing pattern for a full-term infant may include shallow and irregular breathing with a rate of 80 to 100 breaths/minute. chest breathing with nasal flaring of 20 to 40 breaths/minute. abdominal breathing with a rate of 80 to 100 breaths/minute. abdominal/chest breathing movements at a rate of 30 to 60 breaths/minute.
abdominal/chest breathing movements at a rate of 30 to 60 breaths/minute. A normal rate is 30-60 breaths/min.
During a physical examination a 4-month old baby begins to cry. Which assessment finding should the nurse expect at this time? bulging anterior fontanelle bulging posterior fontanelle respiratory rate 70 per minute heart rate 68 beats per minute
bulging anterior fontanelle Increased intracranial pressure produces a bulging, full anterior fontanelle and is seen when a baby cries. By age 4 months the posterior fontanelle should be closed. The average heart rate of a 4-month old should be between 80 and 180 beats per minute. The respiratory rate for this baby should be less than 50 breaths per minute.
During the health history of an 8-month-old client, the nurse asks the mother to list the immunizations that the client has received. This information is important for which part of the history? health maintenance past history health patterns birth history
health maintenance Immunizations are a part of the health maintenance history. The birth history identifies any problems associated with the pregnancy and birth of the client. The past history identifies if the client has any allergies. Health patterns focus on nutrition, elimination, sleep, and activity.
The nurse is preparing to palpate a 1-month old client's abdomen. What technique should the nurse use to facilitate this assessment? hold the legs flexed at the knees and hips distract with a toy remove the diaper assess while being held by the mother
hold the legs flexed at the knees and hips A useful technique to relax the infant to assess the abdomen is to hold the legs flexed at the knees and hips with one hand and palpate the abdomen with the other. Removing the diaper will not facilitate the abdominal assessment. The infant will not be easily distracted at this age by a toy. It will be difficult to determine abdominal organs if the abdomen is being assessed while being held by the mother.
The nurse is planning to instruct a first time mother about her newborn. The nurse should plan to instruct the mother that the newborn will have deciduous teeth by 3 months. is an obligatory nose breather. who drools is preparing for tooth eruption. will develop permanent teeth in the jaw by 6 years of age.
is an obligatory nose breather. Newborns are obligatory nose breathers and, therefore, have significant distress when their nasal passages are obstructed.
A parent brings a 4-week-old newborn to the clinic after observing wave-like motions of the newborn's abdomen and vomiting, but notes that the infant has been passing stool. On assessment of the newborn and after interviewing the parent, the nurse determines the newborn may have which of the following disorders? Hirschsprung disease constipation pyloric stenosis enlarged liver
pyloric stenosis Signs and symptoms of pyloric stenosis include peristaltic waves and vomiting. Hirschsprung disease causes constipation and a rigid abdomen due to the absence of proper nerve function for peristalsis. The newborn is passing stool, so the newborn is not constipated. There is no indication of an enlarged (dysfunctional) liver (yellowing of skin, clay stools).
