Deck 20: Assessment of the Normal Newborn

Question 1

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

Answer 1

0200-0600

Question 2

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.

Answer 2

Depress the tip of the nose.

Question 3

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.

Answer 3

Perform an expanded assessment.

Question 4

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

Question 5

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.

Question 6

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

Question 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

Question 8

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.

Question 9

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

Question 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.

Question 11

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

A)
B)
C)
D)

Question 12

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."

Question 13

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

Question 14

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

Question 15

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

Question 16

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."

Question 17

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

Question 18

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.

Question 19

Infants who develop cephalohematoma are at increased risk for:

A) infection.
B) jaundice.
C) caput succedaneum.
D) erythema toxicum.

Question 20

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.

Question 21

Match each term with the correct definition.

Molding

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

Question 22

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.

Question 23

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

Question 24

Match each term with the correct definition.

Caput succedaneum

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

Question 25

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

Question 26

Match each term with the correct definition.

Cephalohematoma

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