The nurse is performing the initial assessment of a newborn. Which finding should the nurse report to the health care provider?

Question

The nurse is performing the initial assessment of a newborn.  Which finding should the nurse report to the health care provider?

Quizplus · Accepted Answer

11ecbb05_cc21_567b_b433_af119d9b4b2c_MD0009_00 Primitive newborn reflexes help determine the client's neurological status and development. The Moro reflex (ie, startle reflex), present until age 3-6 months, is elicited by quickly lowering the infant's head relative to the body, simulating a falling sensation. It is also a response to sudden loud noises and jarring of the crib. Initially, the newborn extends and raises the arms with fingers fanned out and then curls into the fetal position. Absence of the Moro reflex may indicate an underdeveloped or damaged brain or spinal cord and should be reported to the health care provider (Option A). (Option B) Swollen labia and a thin, white vaginal discharge are normal findings in the first few weeks of life, probably related to maternal hormones. These will subside spontaneously. (Option C) The posterior fontanel is located at the intersection of the sagittal and lambdoid sutures. It is triangle-shaped and smaller than the anterior fontanel, which is diamond-shaped and located at the intersection of the frontal and parietal sutures. (Option D) White pinpoint papules on the newborn's face (milia) are caused by sebaceous material in the follicles. These are normal and will disappear spontaneously within the first month of life. Educational objective: The Moro (startle) reflex is elicited in newborns by simulating a falling sensation; the infant extends and raises the arms and then curls into the fetal position. An absent Moro reflex may indicate brain or spinal cord underdevelopment or damage.

The Nurse Is Performing the Initial Assessment of a Newborn