Chapter 24 Nursing Assessment of the Newborn

Chapter 24   Nursing Assessment of the Newborn

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

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

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

Answer:  3

Explanation:  1. Full sole creases and nails beyond the fingertips will be seen in term infants; scarf sign beyond the midline is an indication of a preterm infant.

2. Deep testes and rugae-covered scrotum are seen in term infants; vernix covering the body is an indication of a preterm infant.
3. All of these characteristics are indications of a preterm infant.
4. 1 cm breast bud, peeling skin, the presence of adipose so that veins are not visible, and rapid recoil of the legs and arms are all indications of term-to-post-term infants.

Page Ref: 445

Cognitive Level:  Application

Client Need&Sub:  Health Promotion and Maintenance

Standards:  QSEN Competencies: Patient-centered care | AACN Essential Competencies: Essential IX: Baccalaureate generalist nursing practice | NLN Competencies: Human flourishing | Nursing/Integrated Concepts: Nursing Process: Assessment/Coordination of care

Learning Outcome:  LO 24.1-Describe the physical and neuromuscular maturity characteristics assessed to determine gestational age of the newborn.

MNL LO:  Use assessment tools to determine gestational age and behavior/sleep-wake patterns of the newborn.

 

2) The nurse is observing a couple interacting with their 2-day-old child. Which of the mother’s statements suggests a potentially abnormal finding in the newborn?

1. “She looks like she’s a little bit cross-eyed.”
2. “There is some white-colored drainage coming from her vagina.”
3. “Her belly looks so round.”
4. “She has some small white specks on the roof of her mouth.”

Answer:  3

Explanation:  1. Transient strabismus (pseudostrabismus) or squinting caused by poor neuromuscular control of eye muscles that gradually regresses in 3 to 4 months may be seen in the newborn.

2. A vaginal discharge composed of thick whitish mucus may be present during the first week of life.
3. Abdominal distention is the first sign of many gastrointestinal abnormalities.
4. On the hard palate and gum margins, Epstein’s pearls, small glistening white specks (keratin-containing cysts) that feel hard to the touch, are often present. They usually disappear in a few weeks and are of no significance.

Page Ref: 463

Cognitive Level:  Evaluating

Client Need&Sub:  Physiological Integrity

Standards:  QSEN Competencies: Patient-centered care | AACN Essential Competencies: Essential VII: Clinical prevention and population health | NLN Competencies: Human flourishing | Nursing/Integrated Concepts: Nursing Process: Evaluation/Health teaching and health promotion

Learning Outcome:  LO 24.2-Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings and possible nursing responses.

MNL LO:  Utilize the findings of the newborn assessment to teach and involve parents in newborn care.

 

3) The nurse is preparing new parents to be discharged with their newborn. The mother asks the nurse why the baby’s eyelids are so swollen. The best response by the nurse is:

1. “Swollen eyelids can happen because of the pressure associated with birth; the swelling should resolve in a few days.”
2. “Newborn babies cry a lot and, as with adults, crying can cause our eyelids to be swollen.”
3. “It’s likely that your baby is developing an infection of the eyelids; I’ll report this to the physician.”
4. “Swollen eyelids are uncommon in newborns and may be an indication of a more serious disorder; if this does not resolve in one week, you need to visit your pediatrician.”

Answer:  1

Explanation:  1. The eyelids are usually edematous during the first few days of life because of the pressure associated with birth.

2. The eyelids are usually edematous during the first few days of life because of the pressure associated with birth.
3. The eyelids are usually edematous during the first few days of life because of the pressure associated with birth.
4. The eyelids are usually edematous during the first few days of life because of the pressure associated with birth.

Page Ref: 459-460

Cognitive Level:  Analyzing

Client Need&Sub:  Health Promotion and Maintenance

Standards:  QSEN Competencies: Patient-centered care | AACN Essential Competencies: Essential VII: Clinical prevention and population health | NLN Competencies: Human flourishing | Nursing/Integrated Concepts: Nursing Process: Implementation/Health teaching and health promotion

Learning Outcome:  LO 24.2-Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings and possible nursing responses.

MNL LO:  Utilize the findings of the newborn assessment to teach and involve parents in newborn care.

 

4) The nurse is assessing a newborn a few minutes after birth. The neonate has overlapping anterior fontanelles and suture lines. The best nursing action is to:

1. Contact the physician immediately.
2. Verify the presence of lanugo.
3. Document the findings.
4. Assess for rectal patency.

Answer:  3

Explanation:  1. There is no need to contact the physician. Overlapping fontanels and sutures are a common variation of normal.

2. Lanugo is not related to overlapping fontanels and sutures, which are a common variation of normal.
3. Because overlapping fontanels and sutures are a common variation of normal, documenting the findings is appropriate.
4. Rectal patency is not related to overlapping fontanels and sutures, which are a common variation of normal.

Page Ref: 457-458

Cognitive Level:  Application

Client Need&Sub:  Physiological Integrity

Standards:  QSEN Competencies: Patient-centered care | AACN Essential Competencies: Essential IX: Baccalaureate generalist nursing practice | NLN Competencies: Human flourishing | Nursing/Integrated Concepts: Nursing Process: Assessment/Coordination of care

Learning Outcome:  LO 24.2-Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings and possible nursing responses.

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