Chapter 28 Nursing Assessment of the Newborn

Chapter 28   Nursing Assessment of the Newborn

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

1) 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?

1. Arm recoil
2. Square window sign
3. Scarf sign
4. Popliteal angle

Answer:  1

Explanation:  1. Arm recoil is slower in healthy but fatigued newborns after birth; therefore, arm recoil is best elicited after the first hour of birth, when the baby has had time to recover from the stress of birth.

Page Ref: 674

Cognitive Level:  Analyzing

Client Need/Sub:  Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards:  QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome:  4 Describe the components of a neurologic assessment and the neurologic/neuromuscular characteristics of the newborn.

MNL LO:  4.2.1 Recognize the timing and components of newborn assessment.

 

 

2) 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?

1. Amount and area of vernix coverage
2. Creases on the sole
3. Size of the areola
4. Body surface temperature

Answer:  1

Explanation:  1. Drying the baby after birth will disturb the vernix and potentially alter the gestational age criterion. The nurse should document the amount and areas of vernix coverage before drying the newborn.

Page Ref: 674

Cognitive Level:  Applying

Client Need/Sub:  Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards:  QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome:  2 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings.

MNL LO:  4.2.1 Recognize the timing and components of newborn assessment.

 

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

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. The mass appeared on the second day after birth.
2. The mass appears larger when the newborn cries.
3. The head appears asymmetrical.
4. The mass appears on only one side of the head.
5. The mass overrides the suture line.

Answer:  1, 4

Explanation:  1. A cephalohematoma is a collection of blood resulting from ruptured blood vessels between the surface of a cranial bone and the periosteal membrane. These areas emerge as defined hematomas between the first and second days.

4. Cephalohematomas can be unilateral or bilateral, but do not cross the suture lines.

Page Ref: 683

Cognitive Level:  Understanding

Client Need/Sub:  Physiological Integrity: Physiological Adaptation

Standards:  QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome:  2 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings.

MNL LO:  4.2.1 Recognize the timing and components of newborn assessment.

 

4) 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 which of the following?

1. Full sole creases, nails extending beyond the fingertips, scarf sign showing the elbow beyond the midline
2. Testes located in the upper scrotum, rugae covering the scrotum, vernix covering the entire body
3. Ear cartilage folded over, lanugo present over much of the body, slow recoil time
4. 1 cm breast bud, peeling skin and veins not visible, rapid recoil of legs and arms to extension

Answer:  3

Explanation:  3. Ear cartilage folded over, lanugo present over much of the body, and slow recoil time are all characteristics of a preterm infant.

Page Ref: 671, 673, 674

Cognitive Level:  Applying

Client Need/Sub:  Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards:  QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome:  1 Describe the physical and neuromuscular maturity characteristics assessed to determine the gestational age of the newborn.

MNL LO:  4.2.3 Differentiate between the various gestational ages of newborns.