Deck 15: Assessing the Newborn and Infant

Question 1

The nurse is conducting an assessment for an infant during a well-baby check-up. When does the nurse expect the anterior fontanel to close?

A) Age 1 to 2 months
B) Age 4 months
C) Age 6 months
D) Age 12 to 18 months

Answer 1

Age 12 to 18 months

Question 2

The nurse is preparing to conduct a physical assessment during a 12-month well-baby visit. In which position should a fearful infant be placed during this assessment?

A) In a car seat
B) On parent's or caregiver's lap
C) Supine on exam table
D) Prone on exam table

Answer 2

On parent's or caregiver's lap

Question 3

The nurse is assessing a newborn who exhibits a poor rooting reflex. Which does the nurse anticipate the newborn will have difficulty with based on this assessment finding?

A) Defecating
B) Feeding
C) Bonding
D) All of the above

Answer 3

Feeding

Question 4

The nurse is assessing an infant whose length was 19 inches at birth. Which is his expected height at 6 months of age?

A) 25 inches
B) 27 inches
C) 29 inches
D) 31 inches

Question 5

Which procedure should be performed first during the physical exam of the newborn?

A) Measurement of the head circumference
B) Auscultation of the heart and lungs
C) Evaluation of the reflexes
D) Otoscopic exam

Question 6

A 2-week-old newborn is accompanied by the mother for the first visit to the clinic. The breastfeeding mother asks, "What should my baby's bowel movements look like?" Which response by the nurse is the most appropriate?

A) "The baby should have one stool a day that is dark brown and formed."
B) "Several soft mustard-colored stools a day is normal."
C) "Hard stools are common in breastfed babies."
D) "The stool should be watery and contain mucus."

Question 7

The nurse is conducting a 2 week well-baby visit for a newborn. Which immunizations are recommended for this newborn?

A) Hepatitis B (if not given at birth)
B) Hepatitis B and diphtheria, pertussis, tetanus (DPT)
C) Hepatitis B and inactivated polio vaccine (IPV)
D) IPV

Question 8

Which medical term is used to describe the white cheeselike substance that covers the skin of newborns at birth?

A) Vernix caseosa
B) Milia
C) Lanugo
D) Erythema toxicum

Question 9

A 4-month-old infant presents with vomiting over the last 12 hours. Which is a good assessment of hydration status?

A) Skin turgor
B) Fontanels
C) Number of wet diapers per day
D) All of the above

Question 10

The nurse is assessing an 11-month-old infant during a well-baby check-up. Which neurologic reflexes does the nurse expect the infant to demonstrate during the visit?

A) Babinski and tonic neck
B) Babinski and sucking
C) Tonic neck and Moro
D) Plantar grasp and Moro

Question 11

The nurse is assessing an infant whose birth weight was 7 lb 8 oz. Which is the expected weight at 1 year?

A) 15 lb
B) 23 lb
C) 33 lb
D) 40 lb

Question 12

The nurse is providing care to several newborn patients during well-baby visits. Which set of vital signs is the most abnormal?

A) Temperature 38°C, heart rate 120, and respirations 34
B) Temperature 39°C, heart rate 135, and respirations 34
C) Temperature 36.8°C, heart rate 140 (crying), and respirations 40
D) Temperature 37.7°C, heart rate 133, and respirations 30

Question 13

Which action by the nurse is most appropriate when performing the Barlow-Ortolani maneuver to assess for congenital hip dislocation on a 2-week-old newborn?

A) Placing the first two fingers over the greater trochanter and the thumb over the inner thighs
B) Placing two thumbs on the shaft of the femur
C) Rotating each joint in a clockwise motion
D) Placing the first two fingers on the symphysis pubis and the thumbs over the lesser trochanter

Question 14

The nurse is assessing a newborn who exhibits continued extrusion of the tongue. Which diagnosis does the nurse anticipate based on this data?

A) Tetralogy of Fallot
B) Diabetes insipidus
C) Diabetes mellitus
D) Down syndrome

Question 15

Which is a key gross motor change that occurs during the first year of life?

A) Beginning to walk
B) Grasping objects
C) Holding a bottle
D) Developing the pincer grasp

Question 16

Which technique will the nurse use when eliciting the Moro reflex during a newborn assessment?

A) Rotate the newborn's head to one side so that the chin is over the shoulder.
B) Place object or finger in the palm of the newborn's hand.
C) Stroke lateral surface of the sole of the newborn's foot.
D) Jar bassinette or let the newborn's head drop back.

Question 17

The nurse is conducting a newborn assessment. The lack of which reflex is often associated with spinal cord problems?

A) Sucking
B) Rooting
C) Trunk incurvation
D) Blink

Question 18

Which term is used to describe the condition in which the foreskin of an uncircumcised penis remains tight and cannot be retracted?

A) Phimosis
B) Varicocele
C) Epididymitis
D) Smegma

Question 19

Most states have mandatory phenylketonuria (PKU) screening several days after birth to rule out phenylalanine amino acids in blood that can cause which disorder?

A) Intellectual disability
B) Diabetes mellitus
C) Down syndrome
D) Iron deficiency anemia

Question 20

A newborn's health history reveals an Apgar score of 4 to 7. Which condition is inferred with this score?

A) Good
B) Excellent
C) Guarded
D) Critical

Question 21

The nurse is conducting a newborn health history assessment. When assessing the use of drugs or alcohol during pregnancy, which questions are appropriate to ask the newborn's mother? Select all that apply.

A) "Did you take any prescription medications during pregnancy?"
B) "Did you take any over-the-counter medications during pregnancy?"
C) "Did you consume coffee or energy drinks during pregnancy?"
D) "Did you consume alcohol during pregnancy?"
E) "Did you experience gestational diabetes during pregnancy?"

Question 22

Which tools are not anticipated when conducting a newborn assessment?

A) Tape measure
B) Goniometer
C) Stethoscope
D) Otoscope

Question 23

Which physical assessment approach is appropriate during the newborn assessment process? Select all that apply.

A) Inspecting the skin
B) Palpating the abdomen
C) Percussing the reflexes
D) Auscultating heart and lung sounds
E) Providing a cool environment to decrease sleepiness

Question 24

The nurse is conducting an assessment for an infant during a well-baby check-up. Which interview questions are appropriate when assessing the integumentary system? Select all that apply.

A) "How is your infant doing now?"
B) "Is your infant gaining weight?'
C) "Have you noted any scaling of your infant's skin?"
D) "Are your infant's nails brittle?"
E) "Can your baby move the head from side to side?

Question 25

The nurse is assessing a newborn whose heart rate is 65, respirations are 24, muscle tone is flaccid, reflexes indicate a weak cry, and the color is blue. Which is the appropriate Apgar score for this newborn?

A) 2
B) 3
C) 4
D) 5

Question 26

The initial assessment of the newborn reveals a heart rate of 100 beats per minute, a weak cry, flexed muscle tone, and pink color with blue extremities. Which Apgar score is most appropriate?

A) 5
B) 6
C) 7
D) 8

Question 27

Which is the reason for keeping the infant covered or under a heat lamp during a newborn assessment?

A) A cold room will make the baby cry.
B) The heart rate will drop if the baby is at room temperature.
C) Newborns cannot control their own body temperature.
D) Respirations will cease if the baby is cold.

Question 28

The nurse anticipates that the chest circumference will equal the head circumference by ________________months of age.

Question 29

The nurse is conducting a newborn assessment and notes that the newborn has an ear malformation. Which will the nurse assess for based on this data?

A) Renal problems
B) Respiratory problems
C) Cardiovascular problems
D) Neurological problems
Completion
Complete each statement.

Question 30

Apnea is defined as respirations that cease for at least ________________seconds.

Question 31

A normal respiratory rate for a newborn is 30 to ________________irregular respirations per minute.

Question 32

An initial newborn assessment reveals a heart rate of 76, a weak cry, slight flexion of extremities, a facial grimace, and a trunk pink in color but blue extremities. Which is an appropriate Apgar score?

A) 2
B) 3
C) 4
D) 5

Question 33

The nurse is conducting an assessment for a newborn who presents with a heart rate of 140, a strong cry is noted, muscle tone is active, reflexes are vigorous, and color is pink with blue hands and feet. Which Apgar score is most appropriate for the newborn?

A) 6
B) 8
C) 9
D) 10

Question 34

The nurse is assessing a newborn who presents with a heart rate of 80, a weak cry, flaccid muscle tone, and blue coloring. Which is the appropriate Apgar score for this newborn?

A) 1
B) 2
C) 3
D) 4

Question 35

The nurse is preparing to conduct a newborn assessment. Which equipment is appropriate for the nurse to use? Select all that apply.

A) Stethoscope
B) Speculum
C) Tape measure
D) Thermometer
E) Penlight

Question 36

Jaundice that occurs within the first ________________hours of life is considered pathological jaundice.

Question 37

The nurse is conducting a newborn assessment. Which findings are considered abnormal? Select all that apply.

A) Pink and moist mucus membranes
B) Intact frenulum
C) Midline uvula
D) White patches on the cheeks and tongue
E) Weak cry