Deck 24: Nursing Assessment of the Newborn

Question 1

A new parent asks why the baby appears to be occasionally cross-eyed. When should the nurse instruct the parent that this finding will resolve?
1) 1 year
2) 2 weeks
3) 2 months
4) 4 months

Answer 1

4

Question 2

While eliciting the Moro reflex in a newborn, the nurse notes that only the right arm moves. What should the nurse immediately assess based upon this finding?
1) The clavicle
2) Babinski reflex
3) The rooting reflex
4) Ortolani maneuver

Answer 2

1

Question 3

The nurse assesses the newborn's ears to be parallel to the outer and inner canthus of the eye. How should the nurse interpret this finding?
1) Prematurity
2) Facial paralysis
3) A normal position
4) A possible chromosomal abnormality

Answer 3

3

Question 4

The nurse notes that a newborn has tremor-like movements. For which health problems should this newborn be further assessed? Select all that apply.
1) Seizures
2) Bilirubinemia
3) Hypocalcemia
4) Hypoglycemia
5) Substance withdrawal

Question 5

The nursing instructor is demonstrating a newborn assessment using the Ballard gestational assessment tool. Which assessment should be performed after the first hour of birth?
1) Scarf sign
2) Arm recoil
3) Popliteal angle
4) Square window sign

Question 6

The nurse is planning to assess a newborn's neurologic status. Which behaviors should the nurse focus on during this assessment? Select all that apply.
1) Cry
2) Reflexes
3) Alertness
4) Motor activity
5) Resting posture

Question 7

The nurse suspects that a newborn needs a complete neurologic examination by a healthcare provider. What finding did the nurse use to make this clinical decision? Select all that apply.

A) Absence of the plantar grasp
B) Absence of the truncal reflex
C) Presence of the stepping reflex
D) Presence of a nonnutritive sucking reflex
E) Presence of bringing the hand to the mouth

Question 8

The nurse is assessing newborns in the nursery. Which assessment finding places a newborn at risk for developing physiologic jaundice?
1) Molding
2) Mongolian spots
3) Cephalohematoma
4) Telangiectatic nevi

Question 9

The nurse wants to demonstrate to a new family their infant's individuality. Which assessment tool should the nurse use?
1) Ortolani maneuver
2) Ballard Maturity Scale
3) Dubowitz Gestational Age Scale
4) Brazelton Neonatal Behavioral Assessment Scale

Question 10

The nurse is assessing a newborn's musculoskeletal status. How should the nurse assess for clubfoot?
1) Stimulate the sole of the foot
2) Adduct the foot and listen for a click
3) Extend the foot and observe for pain
4) Move the foot to midline and determine resistance

Question 11

A new mother is concerned because the anterior fontanelle swells when the newborn cries. What normal findings should the nurse include when teaching the new mother about this concern? Select all that apply.
1) The fontanelles might bulge.
2) The fontanelles might be depressed.
3) The fontanelles can swell with crying.
4) The fontanelles can pulsate with the heartbeat.
5) The fontanelles can swell when stool is passed.

Question 12

The nurse notes that a newborn has a dry scalp. What should the nurse include when teaching the parents about the care of this newborn? Select all that apply.
1) Use mild soap.
2) Use baby shampoo.
3) Wash the scalp daily.
4) Apply oil every other day.
5) Rinse the scalp with hot water.

Question 13

The nurse notes the presence of a cephalohematoma on the head of a newborn. What did the nurse use to make this clinical determination? Select all that apply.
1) The head appears asymmetric.
2) The mass overrides the suture line.
3) The mass appears only on one side of the head.
4) The mass appeared on the second day after birth.
5) The mass appears larger when the newborn cries.

Question 14

The nurse is making an initial assessment of a newborn. Which data would be considered normal? 1. Chest circumference 30 cm, head circumference 29 cm
2) Chest circumference 38 cm, head circumference 31.5 cm
3) Chest circumference 32.5 cm, head circumference 38 cm
4) Chest circumference 31.5 cm, head circumference 33.5 cm

Question 15

A newborn is demonstrating signs of needing comfort and security. What should the nurse instruct the parents about swaddling this infant? Select all that apply.
1) Swaddling should be loose.
2) Swaddling should be done with the arms at the sides.
3) Swaddling helps the newborn control body movements.
4) Swaddling should permit the newborn access to the mouth.
5) Swaddling should be tightly bound around the infant's torso.

Question 16

Before the nurse begins to dry the newborn off after birth, which assessment finding should be documented to ensure an accurate gestational rating on the Ballard gestational assessment tool?
1) Size of the areolae
2) Creases on the sole
3) Body surface temperature
4) Amount and area of vernix coverage

Question 17

During an assessment of a 12-hour-old newborn, the nurse notices pale pink spots on the nape of the neck. How should the nurse document this finding?
1) Nevus flammeus
2) Nevus vasculosus
3) A Mongolian spot
4) Telangiectatic nevi

Question 18

The nurse attempts to take the vital sign of the newborn, but the newborn is crying. What intervention would be appropriate?
1) Taking the vital signs
2) Waiting until the newborn stops crying
3) Placing a gloved finger in the newborn's mouth
4) Swaddling the newborn with several warm blankets in an attempt to calm the newborn

Question 19

A mother of a 16-week-old infant is concerned because she cannot feel the posterior fontanelle on her infant. Which response by the nurse would be most appropriate?
1) "Your baby must be dehydrated."
2) "Bring your infant to the clinic immediately."
3) "This is due to overriding of the cranial bones during labor."
4) "It is normal for the posterior fontanelle to close by 8 to 12 weeks after birth."

Question 20

The nurse explains normal newborn behavior to new parents who are concerned about the baby's desire to be held. Which statement indicates that teaching has been effective?
1) "Some babies are easier to deal with than others."
2) "Our baby spends more time in the active alert phase."
3) "We are lucky to have a baby with a calm disposition."
4) "Cuddliness is a social behavior that some babies have."