Exam 3 OB Newborn Assessment Practice Questions and Correct Answers

When performing a newborn assessment, the nurse should measure the vital signs in the following sequence: A. Pulse, respirations, temperature B.Temperature, pulse, respirations C. Respirations, temperature, pulse D. Respirations, pulse, temperature D: This sequence is least disturbing. Touching with the stethoscope and inserting the thermometer increase anxiety and elevate vital signs. The nurse is aware that a healthy newborn's respirations are: A. 40-50 per minute B. 30-60 per minute C.50-60 per minute D. 60-80 per minute B: Normally the newborn's breathing is abdominal and irregular in depth and rhythm; the rate ranges from 30-60 breaths per minute. A woman delivers a neonate at 42 weeks' gestation. Which physical finding is expected during an examination if this neonate? A. Abundant lanugo B. Absence of sole creases C. Breast bud of 1-2 mm in diameter D. Leathery, cracked, and wrinkled skin D: Neonatal skin thickens with maturity and is often peeling by post term. The primary critical observation for Apgar scoring is the: A. Heart rate B. Respiratory rate C. Presence of meconium D. Evaluation of the Moro reflex A: The heart rate is vital for life and is the most critical observation in Apgar scoring. Respiratory effect rather than rate is included in the Apgar score; the rate is very erratic. A nurse is assessing a newborn infant following circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which of the following initial nursing actions would be most appropriate? A. Document the findings Contact the physician immediately C. Circle the amount of bloody drainage on the dressing and reassess in 30 minutes D. Reinforce the dressing A: A yellow exudate may be noted in 24 hours, and this is a part of normal healing. The nurse would expect that the area would be red with a small amount of bloody drainage. If the bleeding is excessive, the nurse would apply gentle pressure with sterile gauze. If bleeding is not controlled, then the blood vessel may need to be ligated, and the nurse would contact the physician. (Findings are normal, so you would document).