Deck 30: Nursing Assessment of the Newborn

Question 1

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:

A) Full sole creases, nails extending beyond the fingertips, scarf sign showing the elbow beyond the midline
B) Testes located deep in the scrotum, rugae covering the scrotum, vernix covering the entire body
C) Ear cartilage folded over, lanugo present over much of the body, some flexion of arms and legs at rest
D) 1 cm breast bud, peeling skin and veins not visible, rapid recoil of legs and arms to extension

Answer 1

Ear cartilage folded over, lanugo present over much of the body, some flexion of arms and legs at rest

Question 2

A new mother is concerned because the anterior fontanelle swells when the newborn cries. Explaining normal findings concerning the fontanelles, the nurse states that:

A) The fontanelles can swell with crying.
B) The fontanelles might be depressed.
C) The fontanelles can pulsate with the heartbeat.
D) The fontanelles might bulge.
E) The fontanelles can swell when stool is passed.

Answer 2

The fontanelles can swell with crying.
The fontanelles can pulsate with the heartbeat.
The fontanelles can swell when stool is passed.

Question 3

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?

A) "It is normal for the posterior fontanelle to close by 8-12 weeks after birth."
B) "Bring your infant to the clinic immediately."
C) "This is due to overriding of the cranial bones during labor."
D) "Your baby must be dehydrated."

Answer 3

"It is normal for the posterior fontanelle to close by 8-12 weeks after birth."

Question 4

The nurse assesses four newborns. Which of the following assessment findings would place a newborn at risk for developing physiologic jaundice?

A) Cephalhematoma
B) Mongolian spots
C) Telangiectatic nevi
D) Molding

Question 5

The nurse is assessing the gestational age of a 1-hour-old newborn. Which physical characteristics does the nurse assess?

A) Sole creases
B) Amount of breast tissue
C) Amount of lanugo
D) Reflexes
E) Testicular descent

Question 6

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:

A) A normal position.
B) A possible chromosomal abnormality.
C) Facial paralysis.
D) Prematurity.

Question 7

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? The student nurse:

A) Listens to bowel sounds, then assesses the head for skull consistency and size and tension of fontanelles.
B) Checks for Ortolani's sign, then palpates the femoral pulse, then assesses respiratory rate.
C) Determines skin color, then describes the shape of the chest and looks at structures and flexion of the feet.
D) Counts the number of cord vessels, then assesses genitals, then sclera color and eyelids.

Question 8

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?

A) Amount and area of vernix coverage
B) Creases on the sole
C) Size of the areola
D) Body surface temperature

Question 9

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:

A) Nevus vasculosus.
B) Nevus flammeus.
C) Telangiectatic nevi.
D) A Mongolian spot.

Question 10

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?

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

Question 11

The student nurse attempts to take a newborn's vital signs, but the newborn is crying. What nursing action would be appropriate?

A) Place a gloved finger in the newborn's mouth.
B) Take the vital signs.
C) Wait until the newborn stops crying.
D) Place a hot water bottle in the isolette.

Question 12

The nurse suspects clubfoot in the newborn and assesses for the condition by:

A) Adducting the foot and listening for a click.
B) Moving the foot to midline and determining resistance.
C) Extending the foot and observing for pain.
D) Stimulating the sole of the foot.

Question 13

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?

A) Brazelton's Neonatal Behavioral Assessment Scale
B) Ballard Maturity Scale
C) Dubowitz gestational age scale
D) Ortolani's maneuver

Question 14

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?

A) Lanugo mainly gone, little vernix across the body
B) Prominent clitoris, enlarging minora, anus patent
C) Full areola, 5-10mm bud, pinkish-brown in color
D) Skin opaque, cracking at wrists and ankles, no vessels visible

Question 15

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:

A) 2 months.
B) 2 weeks.
C) 1 year.
D) 4 months.

Question 16

The nurse is teaching a class on infant care to new parents. Which statement by a parent indicates that additional teaching is needed?

A) "The white spots on my baby's nose are called milia, and are harmless."
B) "The cheesy white substance in the creases is vernix, and will be absorbed."
C) "The red spots with a white center on my baby are abnormal acne."
D) "Jaundice might develop in my baby when she is a few days old."

Question 17

The student nurse attempts to take the vital sign of the newborn, but the newborn is crying. What nursing intervention would be appropriate?

A) Placing a gloved finger in the newborn's mouth
B) Taking the vital signs
C) Waiting until the newborn stops crying
D) Swaddling the newborn with several warm blankets in an attempt to calm

Question 18

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. The best response by the nurse is:

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

Question 19

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. The nurse's best response is:

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

Question 20

A new mother is concerned about a mass on the newborn's head. The nurse assesses this to be a cephalhematoma based on which characteristics?

A) The mass appeared on the second day after birth.
B) The mass appears larger when the newborn cries.
C) The head appears asymmetrical.
D) The mass appears on only one side of the head.
E) The mass overrides the suture line.

Question 21

The nurse is explaining to a new mother that the newborn behavioral assessment includes: Note: Credit will be given only for all correct choices and for no incorrect choices. Standard Text:

A) Habituation.
B) Motor activity.
C) Self-quieting activity.
D) Cuddliness.
E) Reflexes.

Question 22

The nurse is assessing a newborn. The parents are present. Which statement by the nurse is most important?

A) "Your infant was born with several reflexes. Some help her eat and protect her. I will show you what they look like."
B) "You will be most successful if you put your baby to breast when her eyes are wide open and she is looking around."
C) "The muscle tone of your baby will increase as she gets older. You'll notice her head lagging less in a few weeks."
D) "The umbilical cord stump will dry up and fall off in about 2 weeks. There might be a spot of blood when it falls off."

Question 23

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 the:

A) Ortolani maneuver.
B) Babinski reflex.
C) Clavicle.
D) Gallant reflex.

Question 24

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?

A) "Your baby will respond to you the most if you look directly into his eyes and talk to him."
B) "Each baby is different. Don't try to compare your infant's behavior with any other child's behavior."
C) "If the sound level around your baby is high, the baby will wake up and be fussy or cry."
D) "If your baby is a cuddler, it is because you rocked and talked to her during your pregnancy."

Question 25

The nurse is preparing to assess a newborn's neurological status. Which finding would require an immediate intervention?

A) At rest, the infant has partially flexed arms and the legs drawn up to the abdomen.
B) When the corner of the mouth is touched, the infant turns the head that direction.
C) The infant blinks when the exam light is turned on over the face and body.
D) The right arm is flaccid while the infant brings the left arm and fist upward to the head.

Question 26

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. The nurse should explain that:

A) Newborn risk factors associated with potential hearing loss do not include a family history of hearing loss.
B) Newborns cannot hear, due to mucus accumulated in the middle ear, which takes several days to drain.
C) Newborns who are asleep do not respond to loud noises that are not accompanied by vibrations.
D) Newborns in a noisy nursery are able to habituate to the sounds, and might not react unless a sound is sudden or much louder.

Question 27

The student nurse assesses the pinna of the newborn's ears, and finds them to be parallel with the outer canthus of the eye. The nursing instructor should explain this finding to be:

A) A normal position.
B) A possible chromosomal abnormality.
C) Facial paralysis.
D) Prematurity.

Question 28

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:

A) Nevus vasculosus.
B) Nevus flammeus.
C) Telangiectatic nevi.
D) A Mongolian spot.

Question 29

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?

A) "Some babies are easier to deal with than others."
B) "We are lucky to have a baby with a calm disposition."
C) "Our baby spends more time in the active alert phase."
D) "Cuddliness is a social behavior that some babies have."

Question 30

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:

A) Two months.
B) Two weeks.
C) One year.
D) Four months.

Question 31

The nurse determines the gestational age of an infant to be 40 weeks. Which characteristics are most likely to be observed?

A) Lanugo abundant over shoulders and back
B) Plantar creases over entire sole
C) Pinna of ear springs back slowly when folded.
D) Vernix well distributed over entire body
E) Testes are pendulous, and the scrotum has deep rugae.

Question 32

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? "The behavioral assessment:

A) "Should be done as soon after birth as possible."
B) "Can be performed without input from parents."
C) "Might be incomplete in a 1-hour home visit."
D) "Includes orientation and motor activity."
E) "Can detect neurological anomalies."

Question 33

The nurse is completing a newborn care class. The nurse knows that teaching has been effective if a new parent states:

A) "My baby might open her arms wide and pull her legs up to her tummy if she is passing gas."
B) "If my baby curls his toes downward when I stroke the sole of his foot, he is normal."
C) "When I put my finger in the palm of my daughter's hand, she will curl her fingers and hold on."
D) "I can get my baby to turn his head toward the right if I lift his right arm over his head."

Question 34

When doing a neurologic assessment of a newborn, the nurse recognizes that:

A) Muscle tone is assessed by moving various parts of the newborn's body while the newborn's head remains in a neutral position.
B) The newborn is somewhat hypertonic.
C) Muscle tone should be symmetrical.
D) Shortly after birth, the infant is flaccid at rest.
E) Diminished muscle tone requires further evaluation.

Question 35

The nurse is answering phone calls at the pediatric clinic. Which call should the nurse return first?

A) Mother of a 2-week-old infant who doesn't make eye contact when talked to
B) Father of a 1-week-old infant who sleeps through the noise of an older sibling
C) Father of a 6-day-old infant who responds more to mother's voice than to father's voice
D) Mother of a 3-week-old infant who has begun to suck on the fingers of the right hand

Question 36

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:

A) "Newborns tend to lose about 5% to 10% of their birth weight because of failure to give adequate supplements when breastfeeeding."
B) "Newborns grow approximately 1 inch a month in the first 6 months. You will need to increase feedings to compensate for the growth spurt."
C) "Newborns have an initial weight loss in the first 3-4 days. Your baby's weight loss is normal."
D) "Newborns lose a lot of heat, so make sure you keep the baby's formula warm when you supplement the breast milk."
E) "Keep the baby from getting chilled or too warm, because that can contribute to weight loss."

Question 37

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:

A) Ortolani's maneuver.
B) Babinski's reflex.
C) The clavicle.
D) The Galant reflex.

Question 38

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?" The best response by the nurse is:

A) "Every baby is different. This is just one variation of normal that we see on a regular basis."
B) "This baby might not have a rooting or sucking reflex, because she is premature."
C) "When she is wide awake and alert, she will probably root and suck even if she is early."
D) "She might be too tired from the birthing process and need a couple days to recover."

Question 39

When assessing a full-term newborn, the nurse notes tremor-like movements. The nurse is aware that further evaluation is indicated to rule out:

A) Low spinal cord defects.
B) Hypoglycemia.
C) Hypocalcemia.
D) Substance withdrawal.
E) Neurologic damage.

Question 40

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. These interventions are directed at promoting the parents':

A) Identification of responses or activities that best meet the special needs of their newborn.
B) Ability to evaluate the neurologic capacity of their newborn.
C) Understanding that the baby's temperament will be the same as their own.
D) Positive attachment experiences.
E) Understanding of the newborns' various behaviors.