Question 1

During a routine assessment of a newborn prior to discharge, the nurse finds an axillary temperature of 99.2°F. Which of the following actions by the charge nurse is most appropriate?

Accepted Answer

An axillary temperature of 99.2°F is within the normal range for a newborn, indicating no immediate concern that would necessitate further action such as retaking the temperature, taking a rectal temperature, or calling the health-care provider.

Question 2

A nursing student reports to the charge nurse that she noticed a newborn with a respiratory rate of 48 breaths per minute that included several short pauses to the rhythm that last for 20 to 24 seconds. Which of the following actions by the charge nurse is most appropriate?

Accepted Answer

Pauses in breathing lasting 20 seconds or more in a newborn can indicate apnea, which requires immediate medical evaluation.

Question 3

When measuring the blood pressure of a newborn the nurse notes a decrease of 10 mm Hg in the thigh when compared to the measurement in the arm. This drop in blood pressure is characteristic of:

Accepted Answer

A decrease in blood pressure of 10 mm Hg in the thigh compared to the arm is characteristic of anomalies of the aorta, such as coarctation of the aorta, where there is a narrowing of the aorta that can lead to a pressure gradient between the upper and lower extremities.

Question 4

The nurse observes a newborn for signs of being in the active alert phase. Which of the following is the best description of this phase?

Accepted Answer

In the active alert phase, a newborn may have irregular respirations and show decreased interest in external stimuli, indicating a state of heightened activity and sensitivity.

Question 5

When measuring the initial length and weight of the newborn it is most important for the nurse to:

Accepted Answer

Putting on gloves if the infant has not had an initial bath is crucial to prevent the transmission of infections. This practice adheres to standard precautions, which are designed to protect healthcare workers and patients from the spread of infections.

Question 6

When assessing a newborn's transition to extrauterine life the Apgar score is used to evaluate the following categories:

Accepted Answer

The Apgar score assesses a newborn's transition to extrauterine life by evaluating five specific criteria: heart rate, respiratory rate, muscle tone, reflex irritability, and skin color.

Question 7

When obtaining a newborn's blood pressure, which of the following is most important for the nurse to consider?

Accepted Answer

The size of the blood pressure cuff is crucial when obtaining a newborn's blood pressure because using a cuff that is too large or too small can lead to inaccurate readings. Proper cuff size ensures the accuracy of the measurement.

Question 8

When conducting a newborn assessment of the infant's anterior fontanels it is best for the infant to be:

Accepted Answer

When assessing a newborn's anterior fontanel, it is best for the infant to be sleeping and quiet. This state allows for the most accurate assessment of the fontanel's size and tension, as crying or being active can temporarily alter these characteristics.

Question 9

When assessing a sleeping newborn, the nurse auscultates a heart rate of 102. The nurse knows that this recording is a(n):

Accepted Answer

A heart rate of 102 beats per minute is within the normal range for a newborn, which is typically between 100 and 160 beats per minute.

Question 10

On day 4 postpartum, a mother returns to the clinic for a routine follow-up. Her newborn was 7 lb 8 oz at birth and now weighs 6 lb 3 oz. The nurse realizes that:

Accepted Answer

Weight loss of greater than 10% of birth weight in newborns is a concern and warrants further evaluation. The baby has lost more than 10% of its birth weight (from 7 lb 8 oz to 6 lb 3 oz), which is beyond the normal range of up to 7-10% that can be lost in the first few days of life.

Question 11

After delivery, the midwife places a newborn skin to skin on its mother's chest for 1 hour. Prior to obtaining an initial weight on the newborn, the nurse knows that standard precautions indicate which of the following is true?

Accepted Answer

Standard precautions include wearing gloves when handling a newborn prior to its initial bath to prevent the transmission of infections. This is because the newborn could have been exposed to blood and other body fluids during birth.

Question 12

A new graduate takes an initial weight on a newborn. The newborn weighs 5 lb 3 oz, The new graduate comments to the charge nurse, "This is a small baby, it must be premature." Which of the following is the most appropriate response?

Accepted Answer

The gestational age must be determined to assess if the newborn is premature, as weight alone is not sufficient to make this determination.

Question 13

A nurse is conducting a general assessment of a newborn born 18 hours ago. What action by the nurse best assesses the newborn for jaundice?

Accepted Answer

Blanching the skin on the infant's nose is a common method to assess for jaundice in newborns, as it allows the nurse to observe any yellow discoloration that may indicate jaundice.

Question 14

A nurse is inspecting and palpating the newborn head. Which of the following findings is of concern?

Accepted Answer

A bulging fontanelle can indicate increased intracranial pressure, which is a concerning finding in a newborn.

Question 15

The nurse is assessing a 5-day-old newborn and notices the sclera is yellow. Which of the following does the nurse know is true regarding a jaundiced newborn?

Accepted Answer

Jaundice in newborns typically begins at the head and progresses downward toward the toes.

Question 16

When conducting a newborn assessment, the nurse is inspecting the nose for patency. While occluding the left nostril with a finger, the nurse observes flaring of the right nostril. The nurse knows which of the following to be true regarding the newborn's nose?

Accepted Answer

Infants are obligate nose breathers, meaning they primarily breathe through their noses, especially in the first few months of life. This is why nasal patency is crucial for their breathing.

Question 17

When conducting a newborn assessment of the infant's ears, the nurse claps her hand next to the infant's ear and observes for which of the following expected finding?

Accepted Answer

When a sound is made near a newborn's ear, the expected response is for the infant to turn his or her head toward the sound. This indicates normal hearing and reflex development.

Question 18

When conducting a newborn assessment of the mouth the nurse knows to assess which of the following?

Accepted Answer

The rooting reflex, sucking reflex, and gag reflex are all pertinent to assessing a newborn's mouth. The rooting reflex helps the baby turn its head towards anything that strokes its cheek or mouth, signaling readiness to feed. The sucking reflex is crucial for feeding, and the gag reflex helps prevent choking. The Babinski reflex involves the toes, and the red reflex test is for eye assessment, making them irrelevant for mouth assessment.

Question 19

The nurse is conducting a health screening of a pregnant woman at a local health fair. What data from the psychosocial history should the nurse recognize as being an increased risk for the development of heart defects, developmental delays, and neurological abnormalities?

Accepted Answer

Consuming alcohol during pregnancy is associated with fetal alcohol spectrum disorders, which can lead to heart defects, developmental delays, and neurological abnormalities.

Question 20

The nurse is teaching a nursing student how to assess the heart and lungs of a newborn. Which of the following statements by the nursing student would indicate a correct understanding of the teaching?

Accepted Answer

Assessing a newborn's heart and lungs while they are calm and in a skin-to-skin position with their mother can help keep the baby relaxed, making it easier to hear heart and lung sounds without the interference of crying.

Quiz 19: Assessing the Newborn