Question 1

The nurse is using the New Ballard Score to assess the gestational age of a newborn delivered 4 hours ago. The infant's gestational age is 33 weeks based on early ultrasound and last menstrual period. The nurse expects the infant to exhibit:

Accepted Answer

The New Ballard Score assesses physical and neurological characteristics to estimate gestational age. A gestational age of 33 weeks would be indicated by ear cartilage folded over, lanugo present over much of the body, and some flexion of arms and legs at rest. The other options listed are not consistent with a gestational age of 33 weeks.

Question 2

A new mother is concerned because the anterior fontanelle swells when the newborn cries. Explaining normal findings concerning the fontanelles, the nurse states that:

Accepted Answer

A,C,E

Question 3

The mother of a 16-week-old infant calls the clinic, concerned because she cannot feel the posterior fontanelle on her infant. Which response by the nurse would be most appropriate?

Accepted Answer

It is normal for the posterior fontanelle to close by 8-12 weeks after birth. The anterior fontanelle remains open until approximately 18-24 months of age. There is no need for immediate evaluation unless other signs and symptoms are present. Overriding of cranial bones during labor can cause molding of the head, but this is not related to the absence of the posterior fontanelle. Dehydration would not be the primary cause of fontanelle closure.

Question 4

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

Accepted Answer

Cephalhematoma can lead to an increased breakdown of red blood cells, contributing to higher bilirubin levels and thus increasing the risk for developing physiologic jaundice in newborns.

Question 5

The nurse is assessing the gestational age of a 1-hour-old newborn. Which physical characteristics does the nurse assess?

Accepted Answer

The answer of The nurse is assessing the gestational age...

Question 6

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:

Accepted Answer

Ears that are parallel to the outer and inner canthus of the eye are in a normal position. This is a typical finding and does not indicate any abnormalities.

Question 7

The nurse is working with a student nurse during assessment of a 2-hour-old newborn. Which action indicates that the student nurse understands neonatal assessment? The student nurse:

Accepted Answer

The correct order of neonatal assessment is to first assess vital signs (respiratory rate, heart rate, temperature), then skin color, chest shape, and extremity flexion. Checking for cord vessels and assessing the genitals would come later in the exam. While assessing the head for skull consistency is important, listening to bowel sounds is not necessary at this point. Checking for Ortolani's sign and palpating the femoral pulse are also not necessary for a 2-hour-old newborn.

Question 8

Before the nurse begins to dry off the newborn after birth, which assessment finding should the nurse document to ensure an accurate gestational rating on the Ballard gestational assessment tool?

Accepted Answer

The amount and area of vernix coverage is one of the key factors in determining gestational age with the Ballard gestational assessment tool. The other options (creases on the sole, size of the areola, and body surface temperature) are not relevant to this assessment tool.

Question 9

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:

Accepted Answer

Telangiectatic nevi, also known as "stork bites" or "angel kisses," are common findings in newborns. These are pale pink or red spots that can appear on the nape of the neck, eyelids, or other areas and are caused by dilated capillaries. They typically fade over time.

Question 10

A nursing instructor is demonstrating an assessment on a newborn using the Ballard gestational assessment tool. The nurse explains that which of the following tests should be performed after the first hour of birth, when the newborn has had time to recover from the stress of birth?

Accepted Answer

The arm recoil test should be performed after the first hour of birth when the newborn has had time to recover from the stress of birth. The other tests (square window sign, scarf sign, and popliteal angle) are all part of the Ballard gestational assessment tool but can be performed within the first hour of birth.

Question 11

The student nurse attempts to take a newborn's vital signs, but the newborn is crying. What nursing action would be appropriate?

Accepted Answer

Placing a gloved finger in the newborn's mouth can help soothe and calm the baby, making it easier to take accurate vital signs.

Question 12

The nurse suspects clubfoot in the newborn and assesses for the condition by:

Accepted Answer

Moving the foot to midline and determining resistance is a commonly used method for assessing for clubfoot in newborns. The nurse would gently move the foot towards midline and observe for any resistance or inability to move the foot into a normal position.

Question 13

The nurse wishes to demonstrate to a new family their infant's individuality. Which assessment tool would be most appropriate for the nurse to use?

Accepted Answer

Brazelton's Neonatal Behavioral Assessment Scale is designed to assess an infant's individuality and behavior patterns. It focuses on areas such as motor function, state control, and response to stimuli, all of which can indicate an infant's unique personality traits. The other options do not assess individuality or behavior patterns, but rather gestational age (B and C) or hip dysplasia (D).

Question 14

The student nurse has performed a gestational age assessment of an infant, and finds the infant to be at 32 weeks. On which set of characteristics is the nurse basing this assessment?

Accepted Answer

At 32 weeks gestation, the infant would have a prominent clitoris and enlarging labia minora, which are indicative of this gestational age.

Question 15

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:

Accepted Answer

Cross-eyed appearance or strabismus in infants is common due to their developing vision and should typically resolve by 4 months as their eye muscles strengthen and coordination improves.

Question 16

The nurse is teaching a class on infant care to new parents. Which statement by a parent indicates that additional teaching is needed?

Accepted Answer

The red spots with a white center on a baby's face are actually called infantile acne or neonatal acne, and they are a common and temporary condition. It is important for the nurse to correct the parent's misunderstanding and provide accurate information.

Question 17

The student nurse attempts to take the vital sign of the newborn, but the newborn is crying. What nursing intervention would be appropriate?

Accepted Answer

Placing a gloved finger in the newborn's mouth can help soothe and calm the newborn, making it easier to take accurate vital signs.

Question 18

The nurse is preparing new parents for discharge with their newborn. The father asks the nurse why the baby's head is so pointed and puffy-looking. The best response by the nurse is:

Accepted Answer

This response correctly explains that the baby's head is molded from passing through the birth canal and that it will become more rounded over time. This reassures the parents that the baby's appearance is normal and expected. Option B is not as informative and could potentially make the parents more concerned. Option C is incorrect and could cause unnecessary alarm, as there is no indication in the scenario that the baby sustained brain damage during birth. Option D is also not helpful or informative.

Question 19

The nurse is completing the gestational age assessment on a newborn while in the mother's postpartum room. During the assessment, the mother asks what aspects of the baby are being checked. The nurse's best response is:

Accepted Answer

This response answers the mother's question by stating that the assessment looks at both physical aspects of the baby (making sure the baby has all of its parts) as well as nervous system function (checking brain and nerve function). It also provides a more detailed response than the other options.

Question 20

A new mother is concerned about a mass on the newborn's head. The nurse assesses this to be a cephalhematoma based on which characteristics?

Accepted Answer

A cephalhematoma is a collection of blood between the skull and periosteum that typically appears a few hours to a day after birth (A) and is confined to one side of the head, not crossing suture lines (D).

Quiz 30: Nursing Assessment of the Newborn