Deck 19: Assessing the Newborn

Question 1

The nurse knows that a full-term newborn infant needs to be in a warm environment for which of the following reasons?

A) The newborn has vernix caseosa covering the skin.
B) The newborn has lanugo covering the skin.
C) The newborn is unable to shiver.
D) The newborn's skin is thin and transparent.

Answer 1

The newborn is unable to shiver.

Question 2

You are caring for a new mother who just had her first child. You teach this mother how to support the newborn's head when she is holding her child. Why is this important?

A) The newborn neck is short.
B) The newborn neck is proportionally long.
C) The newborn neck can support the head at a 45-degree angle.
D) The newborn neck is weak and unable to support the head.

Answer 2

The newborn neck is weak and unable to support the head.

Question 3

You are a nurse working in an obstetrical outpatient clinic. A new mother complains of fatigue and then starts to cry loudly. The mother states that she does not want to be alone with her newborn. Which of the following actions should the nurse take?

A) Suggest she send her guests home so she can rest and have the house to herself.
B) Reassure the mother that this is normal and it will get better.
C) Report the findings to her health-care provider immediately.
D) Use distraction by reminding her how lucky she is to have a healthy baby.

Answer 3

Report the findings to her health-care provider immediately.

Question 4

A new mother is sharing how excited she is that her newborn has blue eyes. The nurse knows that the permanent color of the iris is not set until the child is:

A) 2 to 3 months.
B) 5 to 6 months.
C) 12 months.
D) 18 months.

Question 5

The nurse knows that the newborn is at higher risk for developing ear infections because:

A) The Eustachian tubes are short, wide, and horizontal.
B) The Eustachian tubes are long, narrow, and horizontal.
C) The outer ear canal is longer than in an adult.
D) The space between the ears and the nasopharynx is longer than in an adult.

Question 6

In conducting a newborn health assessment, the nurse notices enlarged breasts and a milky drainage from one of the breasts. This finding is a result of:

A) Newborn breast cancer.
B) Release of the maternal hormone prolactin.
C) Retention of the maternal hormone estrogen.
D) A side effect related to the use of Pitocin.

Question 7

The correct procedure to use when measuring head circumference of an infant is for the nurse to:

A) Place the infant in a supine position and measure the greatest diameter of head-occipital frontal area.
B) Place the infant in a prone position and measure the greatest diameter of head-occipital frontal area.
C) Place the infant in a sitting position and measure the greatest diameter of head-occipital frontal area.
D) Place the infant in the mother's lap and measure the greatest diameter of head-occipital frontal area.

Question 8

A nurse measures the circumference of a newborn head and chest and finds the circumference of the head is 12.4 inches and the chest is 13.8 inches. Based on these measurements, the nurse knows which of the following?

A) These are normal findings.
B) The head circumference is normal but the chest circumference is too big.
C) Both the chest and the head circumference are too big.
D) Chest circumference should not be larger than head circumference.

Question 9

The nurse is assessing a newborn with a suspected cephalohematoma. Which of the following findings would be consistent with a cephalohematoma?

A) Some bruising and swelling noted on one side of the head
B) Edema noted on the entire top of the head
C) Molding of the entire shape of the head
D) Blue hands and feet

Question 10

A nurse is doing a heel stick to collect a laboratory sample for a phenylketonuria (PKU) test prior to discharge of a newborn from the hospital. Which question indicates the mother has a basic understanding of reason(s) for sticking her newborn?

A) "I understand the test will determine if the baby is missing something needed for normal growth and development."
B) "I understand the test will prevent my baby from developing newborn jaundice."
C) "I understand the test will measure my baby's blood sugar to prevent hypoglycemia."
D) "I understand the test is a drug screen done before we take a newborn home."

Question 11

When giving a newborn a bath, the newborn starts to cry and the nurse notices the eyelids and the nape of the infant's neck become very red in color. The nurse knows this finding is characteristic of:

A) Lanugo.
B) Vernix caseosa.
C) Mongolian spots.
D) Nevus simplex.

Question 12

A nurse is conducting a review of systems with a new teenage mother who is recovering from a cesarean section. Which of the following questions will encourage the mother to fully express herself and build rapport?

A) "Are you scared to take this baby home?"
B) "How do you plan to take care of yourself and a newborn?"
C) "Why is the baby's father not here to help?"
D) "How do you think your newborn will affect your life?"

Question 13

When using the Ballard Gestational Age Assessment tool on an infant born 2 hours ago, the nurse places one hand below the infant's elbow and, while holding the infant's hand, briefly sets the elbow in flexion and then extension and then releases the infant's hand to observe the angle of recoil. This describes an assessment technique called the:

A) Arm recoil.
B) Square window.
C) Popliteal angle.
D) Scarf sign.

Question 14

When assessing a newborn using the Ballard Gestational Age Assessment tool the nurse assesses skin turgor, color, and texture. The nurse knows the easiest place to assess the infant's skin is in which location?

A) Abdomen
B) Arm
C) Chest
D) Toes

Question 15

A 39-weeks' gestation newborn was born by cesarean section 1 hour ago and the recorded weight is 5 lb 3 oz. This newborn is considered:

A) Post term-birth.
B) Small for gestational age (SGA).
C) Appropriate for gestational age.
D) Large for gestational age (LGA).

Question 16

When assessing a newborn using the Ballard Gestational Age Assessment tool the nurse folds down the pinna of the ear and releases. The ear recoils instantly. This finding is characteristic of a newborn who is:

A) 24 weeks' gestational age.
B) 30 weeks' gestational age.
C) 39 weeks' gestational age.
D) 42 weeks' gestational age.

Question 17

During assessment of a quiet, alert newborn the nurse counts the apical pulse for 1 full minute and finds a heart rate of 130 beats per minute (bpm). The nurse knows that the expected heart rate for this newborn ranges from:

A) 80 to 100 bpm.
B) 90 to 110 bpm.
C) 120 to 160 bpm.
D) 162 to 180 bpm.

Question 18

The Ballard Gestational Age Assessment tool assesses the gestational age of a newborn by assessing which of the following?

A) Neuromuscular and social maturity
B) Physical and social maturity
C) Neuromuscular and physical maturity
D) Physical maturity only

Question 19

A 36-weeks' gestation newborn weighs 9 lb 2 oz. Which of the following comments by the mother indicates a need for further instructions regarding the infant's risk for complications?

A) "Since my baby is so big I will not have to feed so often and can plan on extra sleep."
B) "Since my baby is early I will set my alarm clock to be sure I wake up to nurse more often."
C) "Since my baby is early I will be sure everyone keeps a hat on the baby's head."
D) "I still need to be sure my baby does not lose too much weight the first 3 to 5 days."

Question 20

During assessment of the umbilical cord, a nurse discovers a two-vessel umbilical cord to include one vein and one artery. The nurse needs to know that a two-vessel cord may be associated with which of the following anomalies?

A) Increased risk of cardiac, renal, and neurologic disorders
B) Increased risk of cardiac, renal, and gastrointestinal anomalies
C) Increased risk of gastrointestinal anomalies and neurologic disorders
D) Increased risk of Down syndrome or Turner syndrome

Question 21

During a routine assessment of a newborn prior to discharge, the nurse finds an axillary temperature of 99.2°F. Which of the following actions by the charge nurse is most appropriate?

A) Retake the temperature in 30 minutes.
B) Take a rectal temperature.
C) No action necessary.
D) Call the health-care provider prior to discharge.

Question 22

A nursing student reports to the charge nurse that she noticed a newborn with a respiratory rate of 48 breaths per minute that included several short pauses to the rhythm that last for 20 to 24 seconds. Which of the following actions by the charge nurse is most appropriate?

A) The charge nurse reassures the nursing student that many newborns have short pauses during respiration.
B) The charge nurse explains that any irregularity in the respiratory rate should be reported immediately.
C) The charge nurse reminds the nursing student to be sure to document her findings on the electronic medical record.
D) The charge nurse notifies the health-care provider.

Question 23

When measuring the blood pressure of a newborn the nurse notes a decrease of 10 mm Hg in the thigh when compared to the measurement in the arm. This drop in blood pressure is characteristic of:

A) Acrocyanosis.
B) Anomalies of the aorta.
C) Renal failure.
D) Postural hypotension.

Question 24

The nurse observes a newborn for signs of being in the active alert phase. Which of the following is the best description of this phase?

A) Newborn may smile, vocalize, and respond to people talking to her or him.
B) Newborn's respiratory rate will be regular.
C) Newborn will lay still and focus on objects in front of her or him.
D) Respirations may be irregular and the newborn may not be interested in stimulation.

Question 25

When measuring the initial length and weight of the newborn it is most important for the nurse to:

A) Wait until the infant is in the quiet alert phase.
B) Wait until the infant has had an initial bath to avoid infection.
C) Put on gloves if the infant has not had an initial bath.
D) Record the measurements in inches and centimeters.

Question 26

When assessing a newborn's transition to extrauterine life the Apgar score is used to evaluate the following categories:

A) Heart rate, respiratory rate, reflexes, skin color, and weight.
B) Square window, arm recoil, popliteal angle, scarf sign, heel to ear, and lanugo.
C) Heart rate, respiratory rate, muscle tone, reflex irritability, and skin color.
D) Lanugo, plantar surface, posture, square window, and scarf sign.

Question 27

When obtaining a newborn's blood pressure, which of the following is most important for the nurse to consider?

A) Size of the blood pressure cuff
B) Infant sleep-wake cycle
C) Availability of a blanket to swaddle the infant
D) Availability of outside assistance to restrain the infant's hand or foot

Question 28

When conducting a newborn assessment of the infant's anterior fontanels it is best for the infant to be:

A) Crying.
B) Active and alert.
C) Active and crying.
D) Sleeping and quiet.

Question 29

When assessing a sleeping newborn, the nurse auscultates a heart rate of 102. The nurse knows that this recording is a(n):

A) Episode of tachycardia.
B) Episode of bradycardia.
C) Normal finding.
D) Episode of apnea.

Question 30

On day 4 postpartum, a mother returns to the clinic for a routine follow-up. Her newborn was 7 lb 8 oz at birth and now weighs 6 lb 3 oz. The nurse realizes that:

A) Weight loss of this amount is normal.
B) Weight loss of greater than 2% is a concern.
C) Weight loss of greater than 5% is a concern.
D) Weight loss of greater than 10% is a concern.

Question 31

After delivery, the midwife places a newborn skin to skin on its mother's chest for 1 hour. Prior to obtaining an initial weight on the newborn, the nurse knows that standard precautions indicate which of the following is true?

A) Once a nurse washes his or her hands, he or she may handle the newborn.
B) Once a nurse uses hand sanitizer, he or she may handle the newborn.
C) If the newborn has not had an initial bath, the nurse needs to wear gloves.
D) If the maternal history does not include TORCH infections, the nurse does not need to wear gloves.

Question 32

A new graduate takes an initial weight on a newborn. The newborn weighs 5 lb 3 oz, The new graduate comments to the charge nurse, "This is a small baby, it must be premature." Which of the following is the most appropriate response?

A) "You are correct, this newborn is premature and will need extra precautions."
B) "You must determine the infant's gestational age before you can determine if the newborn is premature."
C) "You are correct, just by looking at this newborn you can determine it is probably just small for gestational age."
D) "This weight is within a normal weight range for a full-term infant."

Question 33

A nurse is conducting a general assessment of a newborn born 18 hours ago. What action by the nurse best assesses the newborn for jaundice?

A) Assessing the newborn's tongue
B) Blanching the skin on the infant's nose
C) Assessing the newborn's gum line
D) Assessing capillary refill of the newborn's fingernails

Question 34

A nurse is inspecting and palpating the newborn head. Which of the following findings is of concern?

A) A diamond-shaped, soft, flat area at the anterior part of the head
B) A triangular-shaped, soft area at the posterior of the head
C) A half-inch laceration on the top of the head
D) A bulging, diamond-shaped area at the anterior part of the head

Question 35

The nurse is assessing a 5-day-old newborn and notices the sclera is yellow. Which of the following does the nurse know is true regarding a jaundiced newborn?

A) Jaundice begins at the toes and moves up.
B) Jaundice begins at the head and moves toward the toes.
C) Jaundice noticed in the eyes is a late sign of newborn jaundice.
D) Jaundice is most common before 24 hours of age.

Question 36

When conducting a newborn assessment, the nurse is inspecting the nose for patency. While occluding the left nostril with a finger, the nurse observes flaring of the right nostril. The nurse knows which of the following to be true regarding the newborn's nose?

A) Infants frequently have continual nasal drainage.
B) Infants will open their mouths to breathe if they have a nasal obstruction.
C) Infants are obligate nose breathers.
D) Flaring of the nostrils is a normal finding.

Question 37

When conducting a newborn assessment of the infant's ears, the nurse claps her hand next to the infant's ear and observes for which of the following expected finding?

A) The infant will turn his or her head away from the sound.
B) The infant will turn his or her head toward the sound.
C) The infant will initiate a rooting reflex.
D) The infant will startle and start to cry.

Question 38

When conducting a newborn assessment of the mouth the nurse knows to assess which of the following?

A) Rooting reflex, sucking reflex, and gag reflex
B) Rooting reflex, Babinski reflex, and red reflex
C) Sucking reflex, gag reflex, and red reflex
D) Sucking reflex, Babinski reflex, and gag reflex

Question 39

The nurse is conducting a health screening of a pregnant woman at a local health fair. What data from the psychosocial history should the nurse recognize as being an increased risk for the development of heart defects, developmental delays, and neurological abnormalities?

A) Smoking during pregnancy
B) Using street drugs during pregnancy
C) Consuming alcohol during pregnancy
D) Having a family history of congenital anomalies

Question 40

The nurse is teaching a nursing student how to assess the heart and lungs of a newborn. Which of the following statements by the nursing student would indicate a correct understanding of the teaching?

A) "As long as the baby is crying I might as well assess the newborn's heart sounds and lungs."
B) "I will place the newborn on the mother's bed so she can observe my assessment."
C) "I am going to skip gloves because they are too big and I am scared to drop the newborn."
D) "While the newborn is asleep and is skin to skin on its mother's chest, I will assess the heart and lungs."

Question 41

A nurse is teaching a prenatal class on breastfeeding. Which of the following statements by the expectant mothers would indicate a correct understanding of breastfeeding?

A) "I plan to make my husband give the baby a bottle of formula at night and I will nurse during the day so I can get some sleep."
B) "I plan to breastfeed this baby because my last child was sick all the time."
C) "The minute I deliver my baby I am going to sleep for 8 hours with no one kicking me."
D) "I heard that if my baby starts cereal at 2 months that he or she will sleep through the night."

Question 42

The nurse is doing a home visit on a breastfeeding mother and a 1-week-old newborn. The mother is concerned that the infant is not getting enough milk. Which of the following is the best response to the mother?

A) "Your infant should have at least two to four wet diapers a day and one to two stools a day."
B) "Your infant should have at least four to six wet diapers a day and one to two stools a day."
C) "Your infant should have at least six to eight wet diapers a day and two to three stools a day."
D) "Your infant should have at least eight to ten wet diapers a day and three to four stools a day."

Question 43

A nurse is teaching newborn care during prenatal classes. Which of the following should be included regarding when to notify the pediatrician?

A) If the infant has vomiting or diarrhea
B) If the infant has a temperature of 99.8°F
C) If the infant has eight wet diapers per day
D) If the umbilical cord does not fall of by day 9

Question 44

The nurse is conducting a neurologic health assessment. Which of the following is an abnormal finding?

A) The nurse offers a finger on the ulnar side of the hand and observes a tight grasp of the newborn's fingers as the nurse gently lifts the infant.
B) The nurse makes a loud noise and the infant extends the arms and legs, fans out the fingers, and brings in both arms and legs.
C) The nurse strokes a finger on the upper edge of the sole of the infant's foot across the ball of the infant's foot and observes fanning of the toes.
D) The nurse brushes the infant's cheek on the left side near the mouth and notices the infant turns the head away and closes the mouth tightly.

Question 45

The nurse is caring for a newborn who had a circumcision procedure 3 hours ago. Which of the following provides a clue that the newborn might be experiencing pain?

A) Infant has a smooth or nonfurrowed brow.
B) Infant is quiet and calm.
C) Infant's eyes are wide open with little blinking.
D) Infant's heart rate is 140 bpm.

Question 46

When conducting a newborn assessment the nurse detects a small tuft of hair at the base of the spine with a sacral dimple. This finding is characteristic of which of the following?

A) Pilonidal dimple
B) Spina bifida
C) Neurologic deficits
D) Hydrocele

Question 47

The nurse is reviewing a newborn's intake and output for the last 36 hours. There is no documentation that the newborn has passed meconium. The nurse inspects the abdomen and finds that the newborn's abdomen appears distended. The nurse is concerned this finding may indicate which of the following?

A) Ambiguous genitalia
B) Intestinal obstruction
C) Dehydration
D) Spina bifida

Question 48

When observing a new graduate nurse doing a newborn abdominal assessment, which technique illustrates a need for further teaching?

A) The nurse places the infant in the supine position.
B) The nurse inspects the umbilical cord to determine the number of vessels.
C) The nurse waits to palpate the abdomen until after a feeding.
D) The nurse uses the bell of the stethoscope to auscultate bowel sounds in all four quadrants.

Question 49

The newborn skin is critical to the transition from intrauterine life. The skin performs which of the following functions? Select all that apply.

A) Acts as a barrier to water loss, light, and irritants
B) Increases the risk of bacteria, viruses, and infection
C) Provides resilience to mechanical trauma
D) Provides sensation and tactile discrimination
E) Maintains thermal regulation

Question 50

You are inspecting the face of a newborn infant and note pearly white spots on the newborn's nose as seen in the above picture. These spots are called ____________________.