Chapter 20 Assessment of the Normal Newborn

Chapter 20  Assessment of the Normal Newborn

Complete Chapter Questions And Answers
 

Sample Questions

MULTIPLE CHOICE

1. The hips of a newborn are examined for developmental dysplasia. Which sign indicates an incomplete development of the acetabulum?
a.
Negative Barlow test
b.
Equal knee heights
c.
Negative Ortolani sign
d.
Thigh and gluteal creases are asymmetric

ANS: D
Asymmetric thigh and gluteal creases may indicate potential dislocation of the hip. If the hip is dislocated, the knee on the affected side will be lower. A positive Ortolani sign yields a clunking sensation and indicates a dislocated femoral head moving into the acetabulum. During a positive Barlow test, the examiner can feel the femoral head move out of the acetabulum.

PTS: 1 DIF: Cognitive Level: Understanding REF: 389
OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

2. Which newborn reflex is elicited by stroking the lateral sole of the infant’s foot from the heel to the ball of the foot?
a.
Babinski
b.
Stepping
c.
Tonic neck
d.
Plantar grasp

ANS: A
The Babinski reflex causes the toes to flare outward and the big toe to dorsiflex. The stepping reflex occurs when infants are held upright, with their heel touching a solid surface, and the infant appears to be walking. The tonic neck reflex (also called the fencing reflex) refers to the posture assumed by newborns when in a supine position. Plantar grasp reflex is similar to the palmar grasp reflex; when the area below the toes is touched, the infant’s toes curl over the nurse’s finger.

PTS: 1 DIF: Cognitive Level: Application REF: 392, 393
OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

3. Infants who develop cephalohematoma are at increased risk for:
a.
infection.
b.
jaundice.
c.
caput succedaneum.
d.
erythema toxicum.

ANS: B
Cephalohematomas are characterized by bleeding between the bone and its covering, the periosteum. Because of the breakdown of the red blood cells within a hematoma, the infants are at greater risk for jaundice. Cephalohematomas do not increase the risk for infections. Caput is an edematous area on the head from pressure against the cervix. Erythema toxicum is a benign rash of unknown cause that consists of blotchy red areas.

PTS: 1 DIF: Cognitive Level: Understanding REF: 387
OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

4. Which action should the nurse take if a discrepancy is found between the measurements of a newborn and the normative criteria?
a.
Remeasure the infant.
b.
Consider this a normal deviation.
c.
Perform an expanded assessment.
d.
Inform the parents so that they can follow the infant’s growth.

ANS: C
An expanded assessment is necessary to look for data to verify the measurements of the infant. Remeasuring the infant is helpful but an expanded assessment would be a better action. A discrepancy is not a normal deviation. An expanded assessment is needed first so as not to alarm the parents unnecessarily.

PTS: 1 DIF: Cognitive Level: Application REF: 390
OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

5. Which explains why a newborn with a congenital defect of the penis should not be circumcised?
a.
There is increased risk of infection.
b.
The foreskin might be needed for future repairs.
c.
A circumcision will make the defect more visible.
d.
There is no medical rationale for a circumcision.

ANS: B
The foreskin may be used to correct a defect. There is no significant increase in infection. A circumcision would not make the defect more noticeable. A circumcision is a decision made by the parents, but in this case the foreskin might be used to correct a defect.

PTS: 1 DIF: Cognitive Level: Understanding REF: 399
OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity