M: Ch 20 assessment of the newborn

Match each term with the correct definition. a. Bleeding between the periosteum and the skull b. An area of localized edema that appears over the vertex of the newborn's head c. Changes in the shape of the head that allow it to pass through the birth canal 24. Molding 25. Cephalohematoma 26. Caput succedaneum

24. ANS: C PTS: 1 DIF: Cognitive Level: Remembering REF: 387 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance NOT: A caput succedaneum is an area of localized edema that appears over the vertex of the newborn's head as a result of pressure against the mother's cervix during labor. Molding refers to changes in the shape of the head that allow it to pass through the birth canal. A cephalohematoma is bleeding between the periosteum and skull as a result of pressure during birth. 25. ANS: A PTS: 1 DIF: Cognitive Level: Remembering REF: 387 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance NOT: A caput succedaneum is an area of localized edema that appears over the vertex of the newborn's head as a result of pressure against the mother's cervix during labor. Molding refers to changes in the shape of the head that allow it to pass through the birth canal. A cephalohematoma is bleeding between the periosteum and skull as a result of pressure during birth. 26. ANS: B PTS: 1 DIF: Cognitive Level: Remembering REF: 387 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance NOT: A caput succedaneum is an area of localized edema that appears over the vertex of the newborn's head as a result of pressure against the mother's cervix during labor. Molding refers to changes in the shape of the head that allow it to pass through the birth canal. A cephalohematoma is bleeding between the periosteum and skull as a result of pressure during birth.

15. The nurse is performing an initial assessment of a newborn and notes retractions, nasal flaring, and tachypnea. The nurse will continue to perform a focused assessment on which system? a. Respiratory b. Cardiovascular c. Gastrointestinal d. Musculoskeletal

ANS: A Tachypnea, a respiratory rate of more than 60 breaths/min, is the most common sign of respiratory distress. Retractions occur when the soft tissue around the bones of the chest is drawn in with the effort of pulling air into the lungs. Xiphoid (substernal) retractions occur when the area under the sternum retracts each time the infant inhales. When the muscles between the ribs are drawn in so that each rib is outlined, intercostal retractions are present. A reflex widening of the nostrils occurs when the infant is receiving insufficient oxygen. Nasal flaring helps decrease airway resistance and increase the amount of air entering the lungs. PTS: 1 DIF: Cognitive Level: Understanding REF: 384 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

2. Which newborn reflex is elicited by stroking the lateral sole of the infant's foot from the heel to the ball of the foot? a. Babinski b. Stepping c. Tonic neck d. Plantar grasp

ANS: A The Babinski reflex causes the toes to flare outward and the big toe to dorsiflex. The stepping reflex occurs when infants are held upright, with their heel touching a solid surface, and the infant appears to be walking. The tonic neck reflex (also called the fencing reflex) refers to the posture assumed by newborns when in a supine position. Plantar grasp reflex is similar to the palmar grasp reflex; when the area below the toes is touched, the infant's toes curl over the nurse's finger. PTS: 1 DIF: Cognitive Level: Application REF: 392, 393 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

17. The nurse is assessing a newborn delivered 24 hours ago for jaundice. What is the best way to evaluate for this finding? a. Depress the tip of the nose. b. Stroke the outer aspect of the foot. c. Place a finger in the palm of the hand. d. Rotate the hips in an upward and outward direction.

ANS: A The nurse assesses for jaundice at least every 8 to 12 hours and is particularly watchful when infants are at increased risk for hyperbilirubinemia. Jaundice is identified by pressing the infant's skin over a firm surface, such as the end of the nose or the sternum. The skin blanches as the blood is pressed out of the tissues, making it easier to see the yellow color that remains. Jaundice is more obvious when the nurse assesses in natural light. Jaundice begins at the head and moves down the body, and the areas of the body involved should be documented. Jaundice becomes visible when the bilirubin level is greater than 5 mg/dL. The Babinski reflex is assessed by stroking the outer aspect of the foot. The grasp reflex is determined by placing a finger in the newborn's palm. The Barlow and Ortolani tests are methods of assessing for hip instability in the newborn period. Both legs should abduct equally in normal infants. Abducting the affected hip may be difficult. A hip click may be felt or heard but is usually normal and is different from the clunk of hip dysplasia when the femoral head moves in the hip socket. PTS: 1 DIF: Cognitive Level: Application REF: 396 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

11. The clients says, "My baby is so thin and wrinkled. It looks like he has too much skin." Which is the most therapeutic response by the nurse to the new client's statement? a. "You sound disappointed about how your infant looks." b. "All mothers are concerned about how their babies look." c. "Don't worry. In no time he'll fill out his skin and look just fine." d. "You know, all the cigarettes you smoked interfered with the nourishment he needed."

ANS: A The nurse should clarify the client's statement and allow her to verbalize her feelings. "All mothers are concerned about how their babies look" generalizes her concerns and does not answer the mother's question. "Don't worry. In no time he'll fill out his skin and look just fine" does not directly answer the mother's question and could leave her feeling like she asked an unacceptable question. "You know, all the cigarettes you smoked interfered with the nourishment he needed" is condescending and hurtful and would not allow for further conversation between the nurse and mother. PTS: 1 DIF: Cognitive Level: Application REF: 408-409 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Psychosocial Integrity

22. Which are early signs of hypoglycemia in the newborn for which the nurse should assess?(Select all that apply.) a. Jitteriness b. Poor feeding c. Respiratory difficulty d. An increase in temperature e. A capillary refill of 2 seconds

ANS: A, B, C Early signs of hypoglycemia include jitteriness and other central nervous system signs and signs of respiratory difficulty, a decrease in temperature, and poor feeding. A capillary refill of 2 seconds is a normal finding in the newborn. PTS: 1 DIF: Cognitive Level: Analysis REF: 395, 396 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

20. The nurse is conducting a body system assessment of the newborn. Which are abnormal findings that the nurse should report? (Select all that apply.) a. Low-set ears b. Yellow sclera c. A doll's eye sign d. Edema of the eyelids e. Absence of the grasp reflex

ANS: A, B, E Low-set ears may indicate chromosomal abnormalities. The sclera should be white or bluish white. A yellow color indicates jaundice. Absence of reflexes may indicate a serious neurologic problem. The doll's eye sign is a normal finding in the newborn; when the head is turned quickly to one side, the eyes move toward the other side. Edema of the eyelids and subconjunctival hemorrhages (reddened areas of the sclera) result from pressure on the head during birth, which causes capillary rupture in the sclera. PTS: 1 DIF: Cognitive Level: Application REF: 392 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

23. The nurse is performing a gestational age assessment on a newborn. Which characteristics indicate a preterm newborn? (Select all that apply.) a. Translucent skin b. Extended limp arms and legs c. The ear springs back when folded d. Square window angle of 45 degrees or less e. Large clitoris and labia minora in the female newborn

ANS: A, B, E The very preterm infant's skin is translucent because it is thin and has little subcutaneous fat beneath the surface. Preterm neonates have immature flexor muscles and little energy or muscle tone. Therefore they have extended and limp arms and legs that offer little resistance to movement by the examiner. In the preterm female infant, the labia majora are small and separated, and the clitoris and labia minora are large by comparison. In the term neonate, the ear springs back to its original position immediately. The more mature the neonate, the smaller the angle of the square window assessment until the palm folds flat against the forearm at term, the result of maternal hormones at the end of pregnancy. PTS: 1 DIF: Cognitive Level: Application REF: 406 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity MATCHING

16. The postpartum nurse is providing care to a woman 2 hours after birth and to her newborn. On review of the newborn's chart, the nurse sees a notation of caput succedaneum. What will the nurse expect to find in the mother's chart? a. Race—non-white b. A longer than usual labor c. Administration of an epidural d. Delivery by cesarean section

ANS: B A caput succedaneum is an area of localized edema that appears over the vertex of the newborn's head as a result of pressure against the mother's cervix during labor. The pressure interferes with blood flow from the area, causing localized edema at birth. The edematous area crosses suture lines, is soft, and varies in size. The longer the labor, the more pronounced the caput. Mongolian spots are associated with infants born to non-white parents. An epidural may be a contributing factor to a prolonged labor, but it is the pressure of the head against the cervix that gives rise to the caput. If labor is prolonged without descent of the head, a cesarean section may follow but is not the cause of the caput. PTS: 1 DIF: Cognitive Level: Analysis REF: 387 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

3. Infants who develop cephalohematoma are at increased risk for: a. infection. b. jaundice. c. caput succedaneum. d. erythema toxicum.

ANS: B Cephalohematomas are characterized by bleeding between the bone and its covering, the periosteum. Because of the breakdown of the red blood cells within a hematoma, the infants are at greater risk for jaundice. Cephalohematomas do not increase the risk for infections. Caput is an edematous area on the head from pressure against the cervix. Erythema toxicum is a benign rash of unknown cause that consists of blotchy red areas. PTS: 1 DIF: Cognitive Level: Understanding REF: 387 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

9. Which nursing action is designed to avoid unnecessary heat loss in the newborn? a. Maintain room temperature at 70° F. b. Place a blanket over the scale before weighing the infant. c. Take the rectal temperature every hour to detect early changes. d. Undress the infant completely for assessments so that they can be finished quickly.

ANS: B Padding the scale prevents heat loss from the infant to a cold surface by conduction. The room temperature should be appropriate to prevent heat loss from convection. Also, if the room is warm enough, radiation will assist in maintaining body heat. Hourly assessments are not necessary for a normal newborn with a stable temperature. Undressing the infant completely will expose the child to cooler room temperatures and cause a drop in body temperature by convection. PTS: 1 DIF: Cognitive Level: Application REF: 390 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

10. The nurse is performing a gestational age assessment on a newborn. Which characteristic shows the greatest gestational maturity? a. The infant's arms and legs are extended. b. There is some peeling and cracking of the skin. c. There are few rugae on the scrotum and the testes are high in the scrotum. d. The arm can be positioned with the elbow beyond the midline of the chest.

ANS: B Peeling, cracking, dryness, and a few visible veins in the skin are signs of maturity in the newborn. Extended arms and legs is a sign of preterm infants. Few rugae on the scrotum show a younger age in the newborn. The arm being able to be positioned with the elbow beyond the midline of the chest is a result of the scarf sign and indicates a newborn of a younger age. PTS: 1 DIF: Cognitive Level: Application REF: 409 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

5. Which explains why a newborn with a congenital defect of the penis should not be circumcised? a. There is increased risk of infection. b. The foreskin might be needed for future repairs. c. A circumcision will make the defect more visible. d. There is no medical rationale for a circumcision.

ANS: B The foreskin may be used to correct a defect. There is no significant increase in infection. A circumcision would not make the defect more noticeable. A circumcision is a decision made by the parents, but in this case the foreskin might be used to correct a defect. PTS: 1 DIF: Cognitive Level: Understanding REF: 399 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

18. An infant at term was born at 0105, or 1:05 AM. The nurse is developing a plan of care for the newborn. During which time range will the nurse plan on performing the assessment to determine a Ballard score? a. 0115-0130 b. 0200-0600 c. 1400-1800 d. 2000-2300

ANS: B The new Ballard score is often used to assess gestational age based on neuromuscular and physical characteristics. It is designed to assess gestational age from 20 to 44 weeks and provides accurate information within 2 weeks. It is most accurate when performed within 12 hours of birth. PTS: 1 DIF: Cognitive Level: Application REF: 406 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

6. A maculopapular rash with a red base and a small white papule in the center is: a. milia. b. Mongolian spots. c. erythema toxicum. d. café-au-lait spots.

ANS: C A maculopapular rash with a red base and a small white papule in the center is a description of erythema toxicum, a normal rash in the newborn. Milia are minute epidermal cysts on the face of the newborn. Mongolian spots are bluish-black discolorations found on dark-skinned newborns, usually on the sacrum. Café-au-lait spots are pale tan (the color of coffee with milk) macules. Occasional spots occur normally in newborns. PTS: 1 DIF: Cognitive Level: Analysis REF: 400 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

19. The nurse is assessing a newborn and notes a nevus flammeus birthmark. Which of the following figures depicts this birthmark? a. b. c. d.

ANS: C A nevus flammeus (port wine stain) is a permanent, flat, pink to dark reddish-purple mark that varies in size and location. Erythema toxicum is a red blotchy area that may have white or yellow papules or vesicles in the center; it is not a birthmark. Mongolian spots are bluish-black marks that resemble bruises. They usually occur in the sacral area but may appear on the buttocks, arms, shoulders, and other areas. A nevus simplex is also called salmon patch, stork bite, or telangiectatic nevus. It is a flat pink or reddish discoloration from dilated capillaries that occurs over the eyelids, just above the bridge of the nose, or at the nape of the neck. PTS: 1 DIF: Cognitive Level: Analysis REF: 400, 401 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity MULTIPLE RESPONSE

4. Which action should the nurse take if a discrepancy is found between the measurements of a newborn and the normative criteria? a. Remeasure the infant. b. Consider this a normal deviation. c. Perform an expanded assessment. d. Inform the parents so that they can follow the infant's growth.

ANS: C An expanded assessment is necessary to look for data to verify the measurements of the infant. Remeasuring the infant is helpful but an expanded assessment would be a better action. A discrepancy is not a normal deviation. An expanded assessment is needed first so as not to alarm the parents unnecessarily. PTS: 1 DIF: Cognitive Level: Application REF: 390 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

12. Which assessment finding of a newborn requires prompt action by the nurse? a. Respiratory rate of 50 breaths/min b. Cyanosis of the extremities c. Pause in breathing lasting 20 seconds d. Pause in breathing for 15 seconds followed by rapid respirations

ANS: C Apnea is a pause in breathing lasting 20 seconds or more, or accompanied by cyanosis, pallor, bradycardia, and/or decreased muscle tone. Apnea is abnormal and requires prompt intervention. A respiratory rate of 50 breaths/min is still within the normal range. Tachypnea is considered to be 60 breaths/min or more. Cyanosis of the extremities or acrocyanosis is normal during the first day after birth and if the infant becomes cold. Periodic breathing is pauses in breathing lasting 5 to 10 seconds without other changes followed by rapid respirations for 10 to 15 seconds. This occurs in some full-term infants during the first few days but is more common in preterm infants. PTS: 1 DIF: Cognitive Level: Application REF: 384 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

14. Inspection of a newborn's head following birth reveals a hard ridged area and significant molding. The anterior and posterior fontanels show no sign of depression. Delivery history indicates that the mother was pushing for over 3 hours and had epidural anesthesia, and vacuum extraction was used. Based on this information the nurse would first: a. continue to monitor newborn and anticipate that molding will subside. b. inspect and document location of fontanels to complete the head assessment. c. contact the neonatologist. d. note findings as being within normal limits as a result of the strenuous birth process.

ANS: C Assessment data reveal a significant finding, and the nurse should suspect craniosynostosis (premature closing of sutures) and therefore should contact the neonatologist immediately. Even though the birth process was difficult and vacuum extraction was used, this does not account for the physical findings. Continuing to monitor is not a prudent action and, because this is more than molding, it will not go away. Although it is important to note the presence of fontanels, the immediate action would be to make the appropriate referral for medical intervention. PTS: 1 DIF: Cognitive Level: Analysis REF: 404 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Safe and Effective Care Environment/Establishing Priorities

13. The nurse is receiving a shift report in the newborn nursery. Which client should the nurse assess first? a. 38-weeks' gestation female newborn with a blood sugar level of 60 mg/dL b. Term male newborn with a noted axillary temperature of 37.2° C (99° F) c. 40-weeks' gestation female newborn with reported poor feed at last attempt d. 39-weeks' gestation male newborn who has been crying prior to initial bath

ANS: C Newborns who are poor feeds may be showing initial signs of hypoglycemia, so this newborn should be assessed first at the start of the shift. Although the newborn is term, and it is more likely to see hypoglycemia with preterm infants, sometimes hypoglycemia is asymptomatic. Blood sugar results are within normal range and the newborn is considered to be term. Temperature is within normal range and the newborn is term. This newborn is considered to be term, and crying alone does not increase risk stratification. PTS: 1 DIF: Cognitive Level: Analysis REF: 396 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Safe and Effective Care Environment

7. A newborn who is a large-for-gestational-age (LGA) infant is in which percentile(s) for weight? a. Below the 90th b. Less than the 10th c. Greater than the 90th d. Between the 10th and 90th

ANS: C The LGA rating is based on weight and is defined as greater than the 90th percentile in weight. An infant between the 10th and 90th percentiles is average for gestational age. An infant in less than the 10th percentile is small for gestational age. PTS: 1 DIF: Cognitive Level: Analysis REF: 411 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

8. A new client asks, "Why are you doing a gestational age assessment on my baby?" The nurse's best response is: a. "It was ordered by your physician." b. "This must be done to meet insurance requirements." c. "It helps us identify infants who are at risk for any problems." d. "The gestational age determines how long the infant will be hospitalized."

ANS: C The nurse should provide the mother with accurate information about various procedures performed on the newborn. Assessing gestational age is a nursing assessment and does not have to be ordered. It is not needed for insurance needs. Gestational age does not dictate hospital stays. Problems that occur because of gestational age may prolong the stay. PTS: 1 DIF: Cognitive Level: Application REF: 411 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

21. To differentiate between caput succedaneum and cephalohematoma in a newborn, the nurse would consider the following clinical information. (Select all that apply.) a. These are both normal presentations because of the birth process and will resolve within 24 to 48 hours. b. Cephalohematoma manifests as a localized area of swelling as compared with caput succedaneum, which appears as a general swelling of the head. c. A cephalohematoma can develop several hours or days after the birth event, whereas caput succedaneum is noted shortly before or immediately after the birth event. d. Edema that crosses suture lines is observed with caput succedaneum. e. With a cephalohematoma, bleeding occurs between the bone and skull.

ANS: C, D, E Cephalohematoma can be detected up to 24 to 48 hours after the birth process. This clinical condition is caused by bleeding between the periosteum and skull and is a serious medical condition. Caput succedaneum occurs in the presence of pressure from the vaginal canal on the fetal head during the birth process. Swelling is localized and crosses the suture line, whereas with cephalohematoma the swelling is more generalized and crosses the suture line. Caput resolves within 12 to 48 hours after the birth event. PTS: 1 DIF: Cognitive Level: Application REF: 387 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

1. The hips of a newborn are examined for developmental dysplasia. Which sign indicates an incomplete development of the acetabulum? a. Negative Barlow test b. Equal knee heights c. Negative Ortolani sign d. Thigh and gluteal creases are asymmetric

ANS: D Asymmetric thigh and gluteal creases may indicate potential dislocation of the hip. If the hip is dislocated, the knee on the affected side will be lower. A positive Ortolani sign yields a clunking sensation and indicates a dislocated femoral head moving into the acetabulum. During a positive Barlow test, the examiner can feel the femoral head move out of the acetabulum. PTS: 1 DIF: Cognitive Level: Understanding REF: 389 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance