Question 1

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:

Accepted Answer

Cross-eyed appearance or strabismus in infants often resolves by the age of 4 months as the infant's vision system develops and strengthens.

Question 2

A mother of a 16-week-old infant calls the clinic,and is concerned because she cannot feel the posterior fontanelle on her infant.Which of the responses by the nurse would be most appropriate?

Accepted Answer

It is normal for the posterior fontanelle to close by 8-12 weeks after birth, so it is not a cause for concern. Option B is not necessary as this is a normal occurrence. Option C may cause unnecessary anxiety for the mother, and Option D is not a likely cause for the absent posterior fontanelle.

Question 3

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:

Accepted Answer

Ears that are in line with the outer and inner canthus of the eye are considered a normal position for a newborn. This finding indicates that there is no abnormality or deformity in the positioning of the ears.

Question 4

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

Accepted Answer

Cephalhematoma can lead to an increased breakdown of red blood cells, contributing to higher bilirubin levels and thus increasing the risk for developing physiologic jaundice in newborns.

Question 5

The nurse is making an initial assessment of the newborn.Which of the following data would be considered normal?

Accepted Answer

Typically, a newborn's head circumference is about 2 cm larger than the chest circumference. The measurements in option A (chest circumference 31.5 cm, head circumference 33.5 cm) align with this general rule, indicating it is a normal finding.

Question 6

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:

Accepted Answer

Telangiectatic nevi, also known as "stork bites" or "angel kisses," are common findings in newborns. These are pale pink or red spots that can appear on the nape of the neck, eyelids, or other areas and are caused by dilated capillaries. They typically fade over time.

Question 7

Before the nurse begins to dry the newborn off after birth,which of the following assessment findings should the nurse document to ensure an accurate gestational rating on the Ballard gestational assessment tool?

Accepted Answer

The amount and area of vernix coverage is one of the factors assessed on the Ballard gestational assessment tool, which helps determine the newborn's gestational age. It is important for the nurse to document this finding before drying the baby off to ensure accuracy in the assessment. The creases on the sole, size of the areola, and body surface temperature are not factors assessed on the Ballard gestational assessment tool.

Question 8

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:

Accepted Answer

If the nurse only assessed movement of the right arm during the Moro reflex, it is important to assess the clavicle as a potential injury or fracture may be causing limited movement on that side. Ortolani's maneuver assesses for hip dislocation, Babinski's reflex tests for upper motor neuron injury, and the Gallant reflex checks for spinal cord damage.

Question 9

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

Accepted Answer

The answer of The student nurse attempts to take the...

Question 10

The parents of a newborn tell the nurse that their infant seems to enjoy being held and that holding him helps calm him when he cries.They ask the nurse why this is so.After explaining newborn behavior,the nurse assesses the parents' learning.Which statement indicates that teaching was effective?

Accepted Answer

Choice D accurately describes the concept of cuddliness as a social behavior that some babies exhibit. The other choices do not demonstrate an understanding of the information provided by the nurse.

Question 11

The nurse suspects clubfoot in the newborn.It is appropriate to:

Accepted Answer

Moving the foot to midline and determining resistance is the appropriate method for screening for clubfoot in newborns. This is commonly known as the Barlow-Ortolani maneuver. Adducting the foot and listening for a click is used to screen for hip dysplasia, extending the foot and observing for pain is not a valid screening method for clubfoot, and stimulating the sole of the foot is a method of assessing neurological function.

Question 12

The nurse wants to demonstrate to a new family their infant's individuality.Which assessment tool would be most appropriate for the nurse to use?

Accepted Answer

The Brazelton Neonatal Behavioral Assessment Scale evaluates an infant's behavioral and neurological responses to stimuli, providing insight into the infant's individual characteristics and temperament. It can be used to help families understand their infant's unique personality and needs. The Ballard Maturity Scale and Dubowitz Gestational Age Scale are primarily used to assess an infant's gestational age and developmental status, while Ortolani's maneuver is used to check for hip dysplasia. None of these tools would provide the same level of insight into an infant's individuality as the Brazelton assessment.

Question 13

A mother is concerned because the anterior fontanelle swells when the newborn cries.What would the nurse include in her teaching to a new mother about the normal findings concerning the fontanelles? Select all that apply.

Accepted Answer

Swelling of the fontanelles when crying or passing stool is normal due to increased intracranial pressure. Pulsation with the heartbeat is also a normal finding.

Question 14

A nursing instructor is demonstrating an assessment on a newborn for the nursing students using the Ballard gestational assessment tool.The nurse explains that which of the following tests should be performed after the first hour of birth?

Accepted Answer

Arm recoil should be performed after the first hour of birth as it is a neurological assessment that tests muscle tone and reflexes, which may not be fully developed until after the first hour. The other tests listed are part of the Ballard gestational assessment tool but are typically performed within the first hour of birth.

Question 15

A new mother is concerned about a mass on the newborn's head.The nurse assesses this to be a cephalhematoma.Which of the following characteristics would indicate a cephalhematoma? Select all that apply.

Accepted Answer

A cephalhematoma typically appears a few hours to a day after birth and is confined to one side of the head, not crossing suture lines.

Quiz 25: Nursing Assessment of the Newborn