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Before drying off the newborn after birth, which assessment finding should the healthcare professional document to ensure an accurate gestational rating on the Ballard gestational assessment tool?
- A. Amount and area of vernix coverage
- B. Creases on the sole
- C. Size of the areola
- D. Body surface temperature
Correct Answer: A
Rationale: To ensure an accurate gestational rating on the Ballard gestational assessment tool, healthcare professionals should document the amount and area of vernix coverage before drying the newborn. Drying the baby after birth could disturb the vernix, potentially affecting the gestational age assessment. Assessing and documenting the vernix coverage beforehand enables a more precise evaluation using the Ballard gestational assessment tool. Choices B, C, and D are incorrect as they are not directly related to gestational rating on the Ballard assessment tool.
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What assessment finding places a newborn at risk for developing physiologic jaundice?
- A. Cephalohematoma
- B. Mongolian spots
- C. Telangiectatic nevi
- D. Molding
Correct Answer: A
Rationale: The correct answer is A, Cephalohematoma. Physiologic jaundice in newborns can occur due to the breakdown of excess red blood cells. A cephalohematoma, a collection of blood caused by ruptured blood vessels between a cranial bone's surface and periosteal membrane, can lead to increased red blood cell breakdown. This increased breakdown can contribute to the development of physiologic jaundice in newborns. Choices B, Mongolian spots, and C, Telangiectatic nevi, are both benign skin conditions and are not directly associated with increased red blood cell breakdown. Choice D, Molding, refers to the shaping of the fetal head during passage through the birth canal and is not related to the development of physiologic jaundice.
What is the most appropriate action to prevent heat loss in a newborn immediately after birth?
- A. Place the newborn in an incubator
- B. Bathe the newborn right away
- C. Dry the newborn thoroughly
- D. Feed the newborn
Correct Answer: C
Rationale: Drying the newborn thoroughly is the most appropriate action to prevent heat loss immediately after birth. This helps to prevent heat loss through evaporation, which is crucial in maintaining the newborn's body temperature. Placing the newborn in an incubator can be a secondary step after ensuring the baby is dry. Bathing the newborn right away is not recommended as it can lead to further heat loss through evaporation. Feeding the newborn is important but not an immediate action to prevent heat loss; ensuring the baby is dry and warm takes precedence.
The healthcare provider is assessing a newborn who is 2 hours old. Which finding requires immediate intervention?
- A. Acrocyanosis
- B. Respiratory rate of 60 breaths per minute
- C. Grunting with nasal flaring
- D. Heart rate of 140 beats per minute
Correct Answer: C
Rationale: Grunting with nasal flaring is a concerning sign of respiratory distress in a newborn that can indicate inadequate oxygenation. This finding requires immediate intervention to ensure the newborn's respiratory status is stabilized and to prevent further complications. Prompt assessment and appropriate intervention are crucial in such cases to prevent respiratory compromise and potential deterioration. Acrocyanosis, which is bluish discoloration of the extremities, is a common finding in newborns and usually resolves on its own. A respiratory rate of 60 breaths per minute and a heart rate of 140 beats per minute are within normal ranges for a newborn and do not indicate immediate intervention is needed.
One of the signs of CHF is shortness of breath. What is the term for shortness of breath when lying down?
- A. Platypnea
- B. Orthopnea
- C. Apnea
- D. Epistaxis
Correct Answer: B
Rationale: Orthopnea is the specific term used to describe shortness of breath when lying down. This condition is commonly seen in patients with congestive heart failure (CHF) due to the redistribution of fluid in the body when changing positions. Platypnea refers to shortness of breath that worsens when sitting or standing, apnea is the cessation of breathing, and epistaxis is the medical term for a nosebleed. Therefore, the correct answer is B (Orthopnea).
The healthcare provider assesses the newborn's ears to be parallel to the outer and inner canthus of the eye. The healthcare provider documents this finding to be which of the following?
- A. A normal position
- B. A possible chromosomal abnormality
- C. Facial paralysis
- D. Prematurity
Correct Answer: A
Rationale: When the top of the ear (pinna) is parallel to the outer and inner canthus of the eye, it is considered a normal position in a newborn. This alignment is an important assessment to ensure normal development and anatomy. Choices B, C, and D are incorrect because the parallel alignment of the ears to the outer and inner canthus of the eye is not indicative of a possible chromosomal abnormality, facial paralysis, or prematurity. It is simply a normal anatomical finding in a newborn.