Pretest Newborn Assessment Questions and Complete Solutions

The nurse is assessing baby boy Henry, who is 2 hr old. She notes that Henry's plantar creases cover his entire foot. Based on this information, what does the nurse determine Henry's gestational age to be? FULL TERM One to two creases appear at approximately 32 weeks gestation. By 36 weeks gestation, creases cover the anterior two-thirds of the foot. At term, creases cover the entire foot. For extremely preterm infants, the nurse measures the foot length from the tip of the great toe to the back of the heel. The nurse is evaluating a new mother following a teaching session. The mother gently brushes the infant's cheek with her nipple and the newborn turns toward that side and opens the lips to suck. This demonstration of the rooting reflex is part of which assessment? NEUROMUSCULAR The rooting reflex is a neuromuscular characteristic and is elicited when the side of the newborn's mouth or cheek is touched. In response, the newborn turns toward that side and opens the lips to suck. Neuromuscular characteristics evaluate the physiological maturity of the newborn. The Apgar score is used to evaluate the physical condition of the newborn and determine the need for immediate resuscitation. Physical characteristics are objective, clinical criteria used to determine gestational age. Vital signs include respirations, apical heart rate, temperature, and blood pressure, if indicated. A preterm infant arrives in the nursery. Which initial assessments will the nurse make on this infant? 1. Gestational age determination 2. Core temperature readings 3. Sings of respiratory distress Accurate assessment of the gestational age of the preterm newborn is imperative to anticipate special needs and problems. Gestational age assessment should be performed on all newborns. Premature infants may exhibit alterations in thermoregulation, are more prone to hypothermia, and need core temperature readings. Premature infants may exhibit alterations in all body systems and are more likely to encounter respiratory issues than term infants. Blood glucose monitoring and a complete blood count may be done but are not part of the essential assessments that need to be performed initially. The nurse is assessing a sleeping, 1-hr-old newborn. Which data would necessitate the need to notify the healthcare provider?