Question 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?

Accepted Answer

A)   Arm recoil
B)   Square window sign
C)   Scarf sign
D)   Popliteal angleE) None of the above
F) B) and C)

Question 2

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

A)   Brazelton Neonatal Behavioral Assessment Scale
B)   New Ballard Score
C)   Dubowitz gestational age scale
D)   Ortolani maneuverE) C) and D)
F) B) and D)

Question 3

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 which of the following?

Accepted Answer

A)   Nevus vasculosus
B)   Nevus flammeus
C)   Telangiectatic nevi
D)   A Mongolian spotE) A) and D)
F) C) and D)

Question 4

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

A)   Lanugo mainly gone, little vernix across the body
B)   Prominent clitoris, enlarging minora, anus patent
C)   Full areola, 5 to 10 m m bud, pinkish-brown in color
D)   Skin opaque, cracking at wrists and ankles, no vessels visibleE) A) and B)
F) A) and C)

Question 5

The nurse is completing a newborn care class. The nurse knows that teaching has been effective if a new parent states which of the following?

Accepted Answer

A)   "My baby might open her arms wide and pull her legs up to her tummy if she is passing gas."
B)   "When I hold my baby upright with one of his feet on the floor, his feet will automatically remain still."
C)   "When I put my finger in the palm of my daughter's hand, she will curl her fingers and hold on."
D)   "I can get my baby to turn his head toward the right if I lift his right arm over his head."E) A) and D)
F) A) and C)

Question 6

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 how long?

Accepted Answer

A)   2 months
B)   2 weeks
C)   1 year
D)   4 monthsE) A) and D)
F) All of the above

Question 7

The parents of a newborn comment to the nurse that their infant seems to enjoy being held, and that holding the baby helps him calm down after crying. They ask the nurse why this happens. After explaining newborn behavior, the nurse assesses the parents' learning. Which statement indicates that teaching was effective?

Accepted Answer

A)   "Some babies are easier to deal with than others."
B)   "We are lucky to have a baby with a calm disposition."
C)   "Our baby spends more time in the active alert phase."
D)   "Cuddliness is a social behavior that some babies have."E) B) and C)
F) All of the above

Question 8

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

Accepted Answer

A)   Place a gloved finger in the newborn's mouth.
B)   Take the vital signs.
C)   Wait until the newborn stops crying.
D)   Place a hot water bottle in the isolette.E) A) and B)
F) A) and C)

Question 9

The nurse is making an initial assessment of the newborn. Which of the following data would be considered normal?

Accepted Answer

A)   Chest circumference 31.5 c m, head circumference 33.5 c m
B)   Chest circumference 30 c m, head circumference 29 c m
C)   Chest circumference 38 c m, head circumference 31.5 c m
D)   Chest circumference 32.5 c m, head circumference 36 c mE) None of the above
F) A) and C)

Question 10

Which of the following are important behaviors to assess in the neurologic assessment?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Accepted Answer

A)   State of alertness
B)   Active posture
C)   Quality of muscle tone
D)   Cry
E)   Motor activityF) B) and D)
G) B) and C)

Question 11

At birth a newborn's head circumference is 13 inches. What should the nurse expect the chest circumference to be in c m? (Round to the nearest whole number.)

Accepted Answer

The answer of At birth a newborn's head circumference is...

Question 12

The newborn's cry should have which of the following characteristics?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Accepted Answer

A)   Medium pitch
B)   Shrillness
C)   Strength
D)   High pitch
E)   LustyF) C) and D)
G) A) and B) A, C, E

Question 13

Before drying 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

A)   Amount and area of vernix coverage
B)   Creases on the sole
C)   Size of the areola
D)   Body surface temperatureE) A) and D)
F) A) and C) A

Question 14

The nurse is working with a mother who has just delivered her third child at 33 weeks' gestation. The mother says to the nurse, "This baby doesn't turn her head and suck like the older two children did. Why?" What is the best response by the nurse?

Accepted Answer

A)   "Every baby is different. This is just one variation of normal that we see on a regular basis."
B)   "This baby might not have a rooting or sucking reflex because she is premature."
C)   "When she is wide awake and alert, she will probably root and suck even if she is early."
D)   "She might be too tired from the birthing process and need a couple of days to recover."E) B) and C)
F) A) and B)

Question 15

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 which of the following?

Accepted Answer

A)   A normal position
B)   A possible chromosomal abnormality
C)   Facial paralysis
D)   PrematurityE) B) and D)
F) C) and D)

Question 16

A new mother is concerned because the anterior fontanelle swells when the newborn cries. Explaining normal findings concerning the fontanelles, the nurse states which of the following?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Accepted Answer

A)   The fontanelles can swell with crying.
B)   The fontanelles might be depressed.
C)   The fontanelles can pulsate with the heartbeat.
D)   The fontanelles might bulge.
E)   The fontanelles can swell when stool is passed.F) C) and E)
G) A) and B) A, C, E

Question 17

At birth a newborn weighed 7 pounds 10 ounces. If the average weight gain is 7 ounces every week for the first 6 months, what weight should the nurse expect when assessing an infant that is 20 weeks old? (Calculate the weight in ounces.)

Accepted Answer

The answer of At birth a newborn weighed 7 pounds...

Question 18

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

A)   "The white spots on my baby's nose are called milia, and are harmless."
B)   "The whitish cheeselike substance in the creases is vernix, and will be absorbed."
C)   "The red spots with a white center on my baby are abnormal acne."
D)   "Jaundice is a yellowish discoloration of skin that if noticed on the 1st day of life should be reported to the physician."E) B) and C)
F) A) and D)

Question 19

The nurse determines the gestational age of an infant to be 40 weeks. Which characteristics are most likely to be observed?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Accepted Answer

A)   Lanugo abundant over shoulders and back
B)   Plantar creases over entire sole
C)   Pinna of ear springs back slowly when folded.
D)   Vernix well distributed over entire body
E)   Testes are pendulous, and the scrotum has deep rugaeF) A) and E)
G) A) and D)

Question 20

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?

Accepted Answer

A)   Full sole creases, nails extending beyond the fingertips, scarf sign showing the elbow beyond the midline
B)   Testes located in the upper scrotum, rugae covering the scrotum, vernix covering the entire body
C)   Ear cartilage folded over, lanugo present over much of the body, slow recoil time
D)   1 c m breast bud, peeling skin and veins not visible, rapid recoil of legs and arms to extensionE) All of the above
F) A) and D)

Exam 27: Nursing Assessment of the Newborn

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?

Correct Answer
verified

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?

Correct Answer
verified

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 which of the following?

Correct Answer
verified

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?

Correct Answer
verified

The nurse is completing a newborn care class. The nurse knows that teaching has been effective if a new parent states which of the following?

Correct Answer
verified

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 how long?

Correct Answer
verified

Correct Answer
verified

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

Correct Answer
verified

The nurse is making an initial assessment of the newborn. Which of the following data would be considered normal?

Correct Answer
verified

Which of the following are important behaviors to assess in the neurologic assessment? Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Correct Answer
verified

At birth a newborn's head circumference is 13 inches. What should the nurse expect the chest circumference to be in c m? (Round to the nearest whole number.)

Correct Answer
verified

The newborn's cry should have which of the following characteristics? Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Correct Answer
verified
A, C, E

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

Correct Answer
verified
A

The nurse is working with a mother who has just delivered her third child at 33 weeks' gestation. The mother says to the nurse, "This baby doesn't turn her head and suck like the older two children did. Why?" What is the best response by the nurse?

Correct Answer
verified

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 which of the following?

Correct Answer
verified

A new mother is concerned because the anterior fontanelle swells when the newborn cries. Explaining normal findings concerning the fontanelles, the nurse states which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Correct Answer
verified
A, C, E

At birth a newborn weighed 7 pounds 10 ounces. If the average weight gain is 7 ounces every week for the first 6 months, what weight should the nurse expect when assessing an infant that is 20 weeks old? (Calculate the weight in ounces.)

Correct Answer
verified

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

Correct Answer
verified

The nurse determines the gestational age of an infant to be 40 weeks. Which characteristics are most likely to be observed? Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Correct Answer
verified

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?

Correct Answer
verified

Exam 27: Nursing Assessment of the Newborn

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?

Correct AnswerverifiedShow Answer

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?

Correct AnswerverifiedShow Answer

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 which of the following?

Correct AnswerverifiedShow Answer

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?

Correct AnswerverifiedShow Answer

The nurse is completing a newborn care class. The nurse knows that teaching has been effective if a new parent states which of the following?

Correct AnswerverifiedShow Answer

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 how long?

Correct AnswerverifiedShow Answer

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

The nurse is making an initial assessment of the newborn. Which of the following data would be considered normal?

Correct AnswerverifiedShow Answer

Which of the following are important behaviors to assess in the neurologic assessment? Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Correct AnswerverifiedShow Answer

At birth a newborn's head circumference is 13 inches. What should the nurse expect the chest circumference to be in c m? (Round to the nearest whole number.)

Correct AnswerverifiedShow Answer

The newborn's cry should have which of the following characteristics? Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Correct AnswerverifiedA, C, E

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

Correct AnswerverifiedA

The nurse is working with a mother who has just delivered her third child at 33 weeks' gestation. The mother says to the nurse, "This baby doesn't turn her head and suck like the older two children did. Why?" What is the best response by the nurse?

Correct AnswerverifiedShow Answer

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 which of the following?

Correct AnswerverifiedShow Answer

A new mother is concerned because the anterior fontanelle swells when the newborn cries. Explaining normal findings concerning the fontanelles, the nurse states which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Correct AnswerverifiedA, C, E

At birth a newborn weighed 7 pounds 10 ounces. If the average weight gain is 7 ounces every week for the first 6 months, what weight should the nurse expect when assessing an infant that is 20 weeks old? (Calculate the weight in ounces.)

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

The nurse determines the gestational age of an infant to be 40 weeks. Which characteristics are most likely to be observed? Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Correct AnswerverifiedShow Answer

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?

Correct AnswerverifiedShow Answer

Correct Answer
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A, C, E

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A

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A, C, E

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