Nokea
What is most descriptive of the shape of the anterior fontanel in a newborn?
- A. Circle
- B. Square
- C. Triangle
- D. Diamond
Correct Answer: D
Rationale: The anterior fontanel is diamond shaped and measures from barely palpable to 4 to 5 cm. The shape of the posterior fontanel is a triangle. Neither of the fontanels is a circle or a square.
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The nurse is assessing the reflexes of a newborn. Stroking the outer sole of the foot assesses which reflex?
- A. Grasp
- B. Perez
- C. Babinski
- D. Dance or step
Correct Answer: C
Rationale: This is a description of the Babinski reflex. Stroking the outer sole of the foot upward from the heel across the ball of the foot causes the big toes to dorsiflex and the other toes to hyperextend. This reflex persists until approximately age 1 year or when the newborn begins to walk. The grasp reflex is elicited by touching the palms or soles at the base of the digits. The digits will flex or grasp. The Perez reflex involves stroking the newborns back when prone; the child flexes the extremities, elevating the head and pelvis. This disappears at ages 4 to 6 months. When the newborn is held so that the sole of the foot touches a hard surface, there is a reciprocal flexion and extension of the leg, simulating walking. This reflex disappears by ages 3 to 4 weeks.
What is the grayish white, cheeselike substance that covers the newborns skin?
- A. Milia
- B. Meconium
- C. Amniotic fluid
- D. Vernix caseosa
Correct Answer: D
Rationale: The vernix caseosa is the grayish white, cheeselike substance that covers a newborns skin.
When doing the first assessment of a male newborn, the nurse notes that the scrotum is large, edematous, and pendulous. What should this be interpreted as?
- A. A hydrocele
- B. An inguinal hernia
- C. A normal finding
- D. An absence of testes
Correct Answer: C
Rationale: A large, edematous, and pendulous scrotum in a term newborn, especially in those born in a breech position, is a normal finding. A hydrocele is fluid in the scrotum, usually unilateral, which usually resolves within a few months. An inguinal hernia may or may not be present at birth. It is more easily detected when the child is crying. The presence or absence of testes should be determined on palpation of the scrotum and inguinal canal. Absence of testes may be an indication of ambiguous genitalia.
Which finding in the newborn is considered abnormal?
- A. Nystagmus
- B. Profuse drooling
- C. Dark green or black stools
- D. Slight vaginal reddish discharge
Correct Answer: B
Rationale: Profuse drooling and salivation are potential signs of a major abnormality. Newborns with esophageal atresia cannot swallow their oral secretions, resulting in excessive drooling. Nystagmus is an involuntary movement of the eyes. This is a common variation in newborns. Meconium, the first stool of newborns, is dark green or black. A pseudomenstruation may be present in normal newborns. This is a blood-tinged or mucoid vaginal discharge.
Which should the nurse use when assessing the physical maturity of a newborn?
- A. Length
- B. Apgar score
- C. Posture at rest
- D. Chest circumference
Correct Answer: C
Rationale: With the newborn quiet and in a supine position, the degree of flexion in the arms and legs can be used for determination of gestational age. Length and chest circumference reflect the newborns size and weight, which vary according to race and gender. Birth weight alone is a poor indicator of gestational age and fetal maturity. The Apgar score is an indication of the newborns adjustment to extrauterine life.