Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig)

Chapter 27 Nursing Assessment of the Newborn

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

Page Ref: 665

Cognitive Level: Analyzing

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

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

Learning Outcome: 1 Identify the major assessment time periods for the newborn.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

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

Page Ref: 664

Cognitive Level: Applying

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

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 3 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

1. 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.

Page Ref: 675

Cognitive Level: Understanding

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 3 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

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 which of the following?
2. Full sole creases, nails extending beyond the fingertips, scarf sign showing the elbow beyond the midline
3. Testes located in the upper scrotum, rugae covering the scrotum, vernix covering the entire body
4. Ear cartilage folded over, lanugo present over much of the body, slow recoil time
5. 1 c m breast bud, peeling skin and veins not visible, rapid recoil of legs and arms to extension

Page Ref: 661

Cognitive Level: Applying

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

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 2 Describe the physical and neuromuscular maturity characteristics assessed to determine the gestational age of the newborn.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

1. 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?
2. Lanugo mainly gone, little vernix across the body
3. Prominent clitoris, enlarging minora, anus patent
4. Full areola, 5 to 10 m m bud, pinkish-brown in color
5. Skin opaque, cracking at wrists and ankles, no vessels visible

Page Ref: 664

Cognitive Level: Understanding

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

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 2 Describe the physical and neuromuscular maturity characteristics assessed to determine the gestational age of the newborn.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

1. The nurse is making an initial assessment of the newborn. Which of the following data would be considered normal?
2. Chest circumference 31.5 c m, head circumference 33.5 c m
3. Chest circumference 30 c m, head circumference 29 c m
4. Chest circumference 38 c m, head circumference 31.5 c m
5. Chest circumference 32.5 c m, head circumference 36 c m

Page Ref: 669

Cognitive Level: Understanding

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

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 2 Describe the physical and neuromuscular maturity characteristics assessed to determine the gestational age of the newborn.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

1. 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?
2. 2 months
3. 2 weeks
4. 1 year
5. 4 months

Page Ref: 676

Cognitive Level: Applying

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

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 7 Describe how to use the assessment procedure and results of the newborn physical, neurologic, and behavioral assessments to teach and involve the parents in their baby's care, and to allay their concerns.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

1. 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?
2. A normal position
3. A possible chromosomal abnormality
4. Facial paralysis
5. Prematurity

Page Ref: 678

Cognitive Level: Understanding

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

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 3 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

1. The nurse assesses four newborns. Which of the following assessment findings would place a newborn at risk for developing physiologic jaundice?
2. Cephalohematoma
3. Mongolian spots
4. Telangiectatic nevi
5. Molding

Page Ref: 675

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅴ. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 3 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

1. 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. What is the best response by the nurse?
2. "His head is molded from fitting through the birth canal. It will become more round."
3. "We refer to that as 'cone head,' which is a temporary condition that goes away."
4. "It might mean that your baby sustained brain damage during birth, and could have delays."
5. "I think he looks just like you. Your head is much the same shape as your baby's."

Page Ref: 674

Cognitive Level: Applying

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

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 3 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

1. The student nurse attempts to take a newborn's vital signs, but the newborn is crying. What nursing action would be appropriate?
2. Place a gloved finger in the newborn's mouth.
3. Take the vital signs.
4. Wait until the newborn stops crying.
5. Place a hot water bottle in the isolette.

Page Ref: 678

Cognitive Level: Applying

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

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 3 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

1. 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?
2. Brazelton Neonatal Behavioral Assessment Scale
3. New Ballard Score
4. Dubowitz gestational age scale
5. Ortolani maneuver

Page Ref: 684

Cognitive Level: Understanding

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

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 7 Describe how to use the assessment procedure and results of the newborn physical, neurologic, and behavioral assessments to teach and involve the parents in their baby's care, and to allay their concerns.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

1. 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. What is the nurse's best response?
2. "I'm checking to make sure the baby has all of its parts."
3. "This assessment looks at both physical aspects and the nervous system."
4. "This assessment checks the baby's brain and nerve function."
5. "Don't worry. We perform this check on all the babies."

Page Ref: 659

Cognitive Level: Applying

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

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 2 Describe the physical and neuromuscular maturity characteristics assessed to determine the gestational age of the newborn.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

1. The nurse is making an initial assessment of the newborn. The findings include a chest circumference of 32.5 c m and a head circumference of 33.5 c m. Based on these findings, which action should the nurse take first?
2. Notify the physician.
3. Elevate the newborn's head.
4. Document the findings in the chart.
5. Assess for hypothermia immediately.

Page Ref: 669

Cognitive Level: Analyzing

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

Standards: Q S E N Competencies: Ⅴ. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 2 Describe the physical and neuromuscular maturity characteristics assessed to determine the gestational age of the newborn.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

1. The nurse is teaching a class on infant care to new parents. Which statement by a parent indicates that additional teaching is needed?
2. "The white spots on my baby's nose are called milia, and are harmless."
3. "The whitish cheeselike substance in the creases is vernix, and will be absorbed."
4. "The red spots with a white center on my baby are abnormal acne."
5. "Jaundice is a yellowish discoloration of skin that if noticed on the 1st day of life should be reported to the physician."

Page Ref: 672

Cognitive Level: Applying

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

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation.

Learning Outcome: 7 Describe how to use the assessment procedure and results of the newborn physical, neurologic, and behavioral assessments to teach and involve the parents in their baby's care, and to allay their concerns.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

1. 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?
2. Nevus vasculosus
3. Nevus flammeus
4. Telangiectatic nevi
5. A Mongolian spot

Page Ref: 673

Cognitive Level: Applying

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

Standards: Q S E N Competencies: Ⅰ. B. 2. Communicate patient values, preferences, and expressed needs to other members of the healthcare team. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 3 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

1. The mother of a 16-week-old infant is concerned because she cannot feel the posterior fontanelle on her infant. Which response by the nurse would be most appropriate?
2. "It is normal for the posterior fontanelle to close by 8 to 12 weeks after birth."
3. "Bring your infant to the clinic immediately."
4. "This is due to overriding of the cranial bones during labor."
5. "Your baby must be dehydrated."

Page Ref: 675

Cognitive Level: Applying

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

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 7 Describe how to use the assessment procedure and results of the newborn physical, neurologic, and behavioral assessments to teach and involve the parents in their baby's care, and to allay their concerns.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

1. Which of the following is a localized, easily identifiable soft area of the infant's scalp, generally resulting from a long and difficult labor or vacuum extraction?
2. Caput succedaneum
3. Cephalohematoma
4. Molding
5. Depressed fontanelles

Page Ref: 675

Cognitive Level: Understanding

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

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 3 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

1. The nurse suspects clubfoot in the newborn and assesses for the condition by doing which of the following?
2. Adducting the foot and listening for a click.
3. Moving the foot to midline and determining resistance.
4. Extending the foot and observing for pain.
5. Stimulating the sole of the foot.

Page Ref: 682

Cognitive Level: Applying

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

Standards: Q S E N Competencies: Ⅴ. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 3 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

1. 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.

Select all that apply.

1. The fontanelles can swell with crying.
2. The fontanelles might be depressed.
3. The fontanelles can pulsate with the heartbeat.
4. The fontanelles might bulge.
5. The fontanelles can swell when stool is passed.

Page Ref: 688

Cognitive Level: Applying

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

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 3 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

1. 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?
2. The student nurse listens to bowel sounds, then assesses the head for skull consistency and size and tension of fontanelles.
3. The student nurse checks for Ortolani's sign, then palpates the femoral pulse, then assesses respiratory rate.
4. The student nurse determines skin color, then describes the shape of the chest and looks at structures and flexion of the feet.
5. The student nurse counts the number of cord vessels, then assesses genitals, then sclera color and eyelids.

Page Ref: 668

Cognitive Level: Understanding

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

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 3 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

1. Approximately what percentage of the newborn's body weight is water?
2. 5% to 10%
3. 90% to 95%
4. 70% to 75%
5. 50% to 60%

Page Ref: 668

Cognitive Level: Remembering

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

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 3 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

1. What condition is due to poor peripheral circulation?
2. Acrocyanosis
3. Mottling
4. Harlequin sign
5. Jaundice

Page Ref: 671

Cognitive Level: Understanding

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

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 3 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

1. 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.

Select all that apply.

1. Lanugo abundant over shoulders and back
2. Plantar creases over entire sole
3. Pinna of ear springs back slowly when folded.
4. Vernix well distributed over entire body
5. Testes are pendulous, and the scrotum has deep rugae

Page Ref: 661, 663

Cognitive Level: Applying

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

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 2 Describe the physical and neuromuscular maturity characteristics assessed to determine the gestational age of the newborn.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

1. The nurse attempts to elicit the Moro reflex on a newborn, and assesses movement of the right arm only. Based on this finding, the nurse immediately assesses for which of the following?
2. Ortolani maneuver
3. Palmar grasping reflex
4. Clavicle
5. Tonic neck reflex

Page Ref: 678

Cognitive Level: Applying

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

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 5 Identify the newborn reflexes that are present at birth.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

1. The nurse is preparing to assess a newborn's neurological status. Which finding would require an immediate intervention?
2. At rest, the infant has partially flexed arms and the legs drawn up to the abdomen.
3. When the corner of the mouth is touched, the infant turns the head that direction.
4. The infant blinks when the exam light is turned on over the face and body.
5. The right arm is flaccid while the infant brings the left arm and fist upward to the head.

Page Ref: 683

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment: Management of Care

Standards: Q S E N Competencies: Ⅴ. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | A A C N 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. | N L N 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 newborn neurologic assessment and the neurologic/neuromuscular characteristics of the newborn.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

1. 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.

Select all that apply.

1. State of alertness
2. Active posture
3. Quality of muscle tone
4. Cry
5. Motor activity

Page Ref: 683

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment: Management of Care

Standards: Q S E N Competencies: Ⅴ. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | A A C N 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. | N L N 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 newborn neurologic assessment and the neurologic/neuromuscular characteristics of the newborn.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

1. 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?
2. "My baby might open her arms wide and pull her legs up to her tummy if she is passing gas."
3. "When I hold my baby upright with one of his feet on the floor, his feet will automatically remain still."
4. "When I put my finger in the palm of my daughter's hand, she will curl her fingers and hold on."
5. "I can get my baby to turn his head toward the right if I lift his right arm over his head."

Page Ref: 667

Cognitive Level: Applying

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

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation.

Learning Outcome: 5 Identify the newborn reflexes that are present at birth.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

1. 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?
2. "Every baby is different. This is just one variation of normal that we see on a regular basis."
3. "This baby might not have a rooting or sucking reflex because she is premature."
4. "When she is wide awake and alert, she will probably root and suck even if she is early."
5. "She might be too tired from the birthing process and need a couple of days to recover."

Page Ref: 691

Cognitive Level: Analyzing

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

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 5 Identify the newborn reflexes that are present at birth.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

1. The nurse is cross-training maternal-child health unit nurses to provide home-based care for parents after discharge. Which statements indicate that additional teaching is required?

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

Select all that apply.

1. "The behavioral assessment should be done as soon after birth as possible."
2. "The behavioral assessment can be performed without input from parents."
3. "The behavioral assessment might be incomplete in a 1-hour home visit."
4. "The behavioral assessment includes orientation and motor activity."
5. "The behavioral assessment can detect neurological impairments."

Page Ref: 684

Cognitive Level: Applying

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

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation.

Learning Outcome: 6 Correlate normal behavioral characteristics of the newborn with variations that may be present.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

1. 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?
2. "Some babies are easier to deal with than others."
3. "We are lucky to have a baby with a calm disposition."
4. "Our baby spends more time in the active alert phase."
5. "Cuddliness is a social behavior that some babies have."

Page Ref: 684

Cognitive Level: Analyzing

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

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation.

Learning Outcome: 6 Correlate normal behavioral characteristics of the newborn with variations that may be present.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

1. The nurse is teaching a group of new parents about their infants. The infants are all 4 weeks of age or younger. Which statement should the nurse include?
2. "Your baby will respond to you the most if you look directly into his eyes and talk to him."
3. "Each baby is different. Don't try to compare your infant's behavior with any other child's behavior."
4. "If the sound level around your baby is high, the baby will wake up and be fussy or cry."
5. "If your baby is a cuddler, it is because you rocked and talked to her during your pregnancy."

Page Ref: 684

Cognitive Level: Applying

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

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning.

Learning Outcome: 6 Correlate normal behavioral characteristics of the newborn with variations that may be present.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

1. The nurse is answering phone calls at the pediatric clinic. Which call should the nurse return first?
2. Mother of a 2-week-old infant who doesn't make eye contact when talked to
3. Father of a 1-week-old infant who sleeps through the noise of an older sibling
4. Father of a 6-day-old infant who responds more to mother's voice than to father's voice
5. Mother of a 3-week-old infant who has begun to suck on the fingers of the right hand

Page Ref: 684

Cognitive Level: Applying

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

Standards: Q S E N Competencies: Ⅴ. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | A A C N Essentials Competencies: Ⅸ. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network. | N L N Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning.

Learning Outcome: 6 Correlate normal behavioral characteristics of the newborn with variations that may be present.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

1. 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.

Select all that apply.

1. Medium pitch
2. Shrillness
3. Strength
4. High pitch
5. Lusty

Page Ref: 686

Cognitive Level: Applying

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

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning.

Learning Outcome: 3 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

1. At 3 weeks a newborn weighs 8 l b s. 1 ounce. What percent of this body weight should the nurse explain to the mother as being water? (Calculate the average weight in ounces to the first decimal point.)

Page Ref: 677

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies:

Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning.

Learning Outcome: 3 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

1. At birth a newborn measured 20 inches. What length should the nurse instruct the mother to expect the baby to be at 4 months? (Calculate the anticipated length in c m and round to the nearest whole number.)

Page Ref: 669

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning.

Learning Outcome: 3 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

1. 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.)

Page Ref: 669

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N 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. | N L N Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment: Nursing Process.

Learning Outcome: 3 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

1. 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.)

Page Ref: 669

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N 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. | N L N Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment: Nursing Process.

Learning Outcome: 3 Summarize the components of a systematic physical newborn assessment and the significance of normal variations and abnormal findings.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.

1. While conducting a home visit, the nurse observes the father of a newborn hold the infant so that the following is observed. What should the nurse explain to the parents about this behavior?

1. This is abnormal and should be reported.
2. This will disappear between 4 and 8 weeks of age.
3. It means the child will begin walking at an early age.
4. The infant should be given more formula when this occurs.

Page Ref: 667

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning.

Learning Outcome: 5 Identify the newborn reflexes that are present at birth.

M N L L O: Demonstrate ability to perform assessment and interpret data for the newborn.