A nurse is beginning a newborn's physical assessment and notes ...

[Mr3Hunna]

A nurse is beginning a newborn's physical assessment and notes that the infant is jumpy and seems irritable when being handled and when the nurse or parents speak. What action by the nurse is best?
 
  A.
  Ask the mother to attempt to breastfeed the infant.
  B.
  Conduct the assessment quickly then swaddle the baby.
  C.
  Increase the heat in the room so the baby won't get chilled.
  D.
  Postpone the assessment until the infant has calmed.

Question 2

A nurse is assessing an infant who has a large bruise around his neck and face from a nuchal cord. What other assessment finding correlates with this condition?
 
  A.
  Elevated serum bilirubin
  B.
  Irritability with gentle handing
  C.
  Large-for-gestational-age measurements
  D.
  Obvious vertebral defects

[Ahnyah]

Answer to Question 1

ANS: D
An infant who seems irritable and overreacts to voices, touch, or movement is displaying disorganized behavior. The nurse should postpone the physical examination until the infant has been calmed. To continue the assessment would risk increasing the baby's behavioral disorganization and would be disruptive for the infant. The other actions are not appropriate in this situation, although swaddling can help calm the baby, as can cuddling, rocking, and gentle holding.

Answer to Question 2

ANS: A
Infants born with a nuchal cord often demonstrate significant bruising to the face and neck. This may be upsetting to the parents. Irritability with handling might be related to damage from birth trauma. Large-for-gestational-age infants often have bruising related to extraction techniques during a difficult birth. Obvious vertebral defects are associated with neural tube anomalies and can be seen in children with hairy pigmented skin lesions and hairy nevi located in the posterior midline area near the spinal column.