Deck 25: Nursing Assessment of the Newborn

Question 1

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.

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

Answer 1

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

Question 2

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?

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

Answer 2

Arm recoil

Question 3

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)Swaddling the newborn with several warm blankets in an attempt to calm
D)Waiting until the newborn stops crying

Answer 3

Placing a gloved finger in the newborn's mouth

Question 4

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

Question 5

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)Facial paralysis.
C)A possible chromosomal abnormality.
D)Prematurity.

Question 6

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

A)Stimulate the sole of the foot.
B)Move the foot to midline and determine resistance.
C)Extend the foot and observe for pain.
D)Adduct the foot and listen for a click.

Question 7

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?

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

Question 8

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

Question 9

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?

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

Question 10

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?

A)Ortolani's maneuver
B)Ballard Maturity Scale
C)Brazelton Neonatal Behavioral Assessment Scale
D)Dubowitz Gestational Age Scale

Question 11

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

A)Chest circumference 38 cm, head circumference 31.5 cm
B)Chest circumference 31.5 cm, head circumference 33.5 cm
C)Chest circumference 32.5 cm, head circumference 36 cm
D)Chest circumference 30 cm, head circumference 29 cm

Question 12

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

Question 13

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.

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

Question 14

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

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

Question 15

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?

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