Posttest Newborn Assessments Review Questions and Complete Solutions

The nurse is assessing a newborn right after birth. Which assessment will be most helpful initially in identifying an at-risk newborn? the newborn's APGAR SCORE The initial Apgar score will be most helpful to the nurse in determining the newborn's risks because it reveals information about movement, respiratory effort, muscle tone, skin color, reflexes, and pulse rate. The newborn's color is a useful assessment, but color along with the other assessments in the Apgar score will give more information. The mother's pregnancy history will give the nurse some information about the newborn, but the Apgar score will give the nurse more information about the infant's risk factors. Respiratory effort is an important aspect of the Apgar score, but if all information from the Apgar scoring is used, the nurse will have much more information about the possibility of complications. The nurse is assessing the general appearance of a newborn. Which data will the nurse document as part of this assessment? POSTURE AT REST RELATIONSHIP OF HEAD SIZE TO BODY The newborn should be observed in the resting position. Observing the relationship of the size of the head to the body is a component of assessing the general appearance of the newborn. Newborns have a large head when compared to their body. Assessment of general appearance requires observation techniques. Assessing rectal temperature requires the use of a thermometer, insertion of the device into the rectum, and positioning of the newborn to prevent harm, which involves the nurse disturbing the newborn's natural position and emotional state. Assessment of lung sounds is a component of the physical assessment, not a component of the newborn's general appearance. Apgar scoring is performed immediately after birth to determine the need for resuscitation or other interventions; it is not a component of assessing the general appearance of the newborn. The nurse performs a gestational age assessment, as part of the newborn assessment, to evaluate physical characteristics. Which data will the nurse collect as part of the gestational assessment for this newborn? SOLE CREASES Physical characteristics generally include sole creases, amount of breast tissue, amount of lanugo, cartilaginous development of the ear, testicular descent, and scrotal rugae or labial development. The scarf sign, the Moro or startle reflex, and the square window sign are all components of neuromuscular development.