A nurse is assessing a newborn that was just born. Which newborn ...

[EY67]

A nurse is assessing a newborn that was just born. Which newborn finding will cause the nurse to intervene immediately?
 
  a. Molding
  b. A lack of reflexes
  c. Cyanotic hands and feet
  d. A soft, protuberant abdomen

Question 2

A nurse performs an assessment on a healthy newborn. Which assessment finding will the nurse document as normal?
 
  a. Cyanosis of the feet and hands for the first 48 hours
  b. Triangle-shaped anterior fontanel
  c. Sporadic motor movements
  d. Weight of 4800 grams

[Jossy]

Answer to Question 1

ANS: B
A lack of reflexes must be addressed quickly. Assessment of these reflexes is vital because the newborn depends largely on reflexes for survival and in response to its environment. Molding, or overlapping of the soft skull bones, allows the fetal head to adjust to various diameters of the maternal pelvis and is a common occurrence with vaginal births. Normal physical characteristics include the continued presence of lanugo on the skin of the back; cyanosis of the hands and feet for the first 24 hours; and a soft, protuberant abdomen.

Answer to Question 2

ANS: C
Movements in the newborn are generally sporadic, but they are symmetric and involve all four extremities. Cyanosis of the hands and feet is normal for the first 24 hours, not 48 hours. The diamond shape of the anterior fontanel and the triangular shape of the posterior fontanel are found between the unfused bones of the skull. The average newborn is 2700 to 4000 grams (6 to 9 pounds), not 4800 grams.

[EY67]

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[Viet Thy]

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