Chapter 27 Nursing Assessment of the Newborn
1) A nursing instructor is demonstrating an assessment on a newborn using
the Ballard gestational assessment tool. The nurse explains that which of the
following tests should be performed after the first hour of birth, when the
newborn has had time to recover from the stress of birth?
1. Arm recoil
2. Square window sign
3. Scarf sign
4. Popliteal angle
Answer: 1 Explanation: 1. Arm recoil is slower in healthy but fatigued
newborns after birth; therefore, arm recoil is best elicited after the first hour
of birth, when the baby has had time to recover from the stress of birth.
Page Ref: 674
Cognitive Level: Analyzing
Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum
and Newborn Care
Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple
dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1.
Conduct comprehensive and focused physical, behavioral, psychological,
spiritual, socioeconomic, and environmental assessments of health and illness
parameters in patients, using developmentally and culturally appropriate
approaches. | NLN Competencies: Relationship-Centered Care: Factors that
contribute to or threaten health. | Nursing/Integrated Concepts: Nursing
Process: Assessment
Learning Outcome: 4 Describe the components of a neurologic assessment
and the neurologic/neuromuscular characteristics of the newborn.
MNL LO: 4.2.1 Recognize the timing and components of newborn assessment.
1
Copyright 2016 Pearson Education, Inc.
2) Before the nurse begins to dry off the newborn after birth, which assessment
finding should the nurse document to ensure an accurate gestational rating on
the Ballard gestational assessment tool?
,1. Amount and area of vernix coverage
2. Creases on the sole
3. Size of the areola
4. Body surface temperature
Answer: 1
Explanation: 1. Drying the baby after birth will disturb the vernix and
potentially alter the gestational age criterion. The nurse should document the
amount and areas of vernix coverage before drying the newborn.
,Page Ref: 674
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum
and Newborn Care
Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple
dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1.
Conduct comprehensive and focused physical, behavioral, psychological,
spiritual, socioeconomic, and environmental assessments of health and illness
parameters in patients, using developmentally and culturally appropriate
approaches. | NLN Competencies: Relationship-Centered Care: Factors that
contribute to or threaten health. | Nursing/Integrated Concepts: Nursing
Process: Assessment
Learning Outcome: 2 Summarize the components of a systematic physical
newborn assessment and the significance of normal variations and abnormal
findings.
MNL LO: 4.2.1 Recognize the timing and components of newborn
assessment.
2
Copyright 2016 Pearson Education, Inc.
3) A new mother is concerned about a mass on the newborns head. The nurse
assesses this to be a cephalohematoma based on which characteristics?
Note: Credit will be given only if all correct choices and no incorrect choices
are selected.
Select all that apply.
1. The mass appeared on the second day after birth.
2. The mass appears larger when the newborn cries.
3. The head appears asymmetrical.
4. The mass appears on only one side of the head.
5. The mass overrides the suture line.
Answer: 1, 4
Explanation: 1. A cephalohematoma is a collection of blood resulting from
ruptured blood vessels between the surface of a cranial bone and the
, periosteal membrane. These areas emerge as defined hematomas between the
first and second days.
4. Cephalohematomas can be unilateral or bilateral, but do not cross the
suture lines.
Page Ref: 683
Cognitive Level: Understanding
Client Need/Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple
dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1.
Conduct comprehensive and focused physical, behavioral, psychological,
spiritual, socioeconomic, and environmental assessments of health and illness
parameters in patients, using developmentally and culturally appropriate
approaches. | NLN Competencies: Relationship-Centered Care: Factors that
contribute to or threaten health. | Nursing/Integrated Concepts: Nursing
Process: Assessment
Learning Outcome: 2 Summarize the components of a systematic physical
newborn assessment and the significance of normal variations and abnormal
findings.
MNL LO: 4.2.1 Recognize the timing and components of newborn assessment.
3
Copyright 2016 Pearson Education, Inc.
4) The nurse is using the New Ballard Score to assess the gestational age of a
newborn delivered 4 hours ago. The infants gestational age is 33 weeks based
on early ultrasound and last menstrual period. The nurse expects the infant to
exhibit which of the following?
1. Full sole creases, nails extending beyond the fingertips, scarf sign showing
the elbow beyond the midline
2. Testes located in the upper scrotum, rugae covering the scrotum, vernix
covering the entire body
3. Ear cartilage folded over, lanugo present over much of the body, slow
recoil time
4. 1 cm breast bud, peeling skin and veins not visible, rapid recoil of legs and
1) A nursing instructor is demonstrating an assessment on a newborn using
the Ballard gestational assessment tool. The nurse explains that which of the
following tests should be performed after the first hour of birth, when the
newborn has had time to recover from the stress of birth?
1. Arm recoil
2. Square window sign
3. Scarf sign
4. Popliteal angle
Answer: 1 Explanation: 1. Arm recoil is slower in healthy but fatigued
newborns after birth; therefore, arm recoil is best elicited after the first hour
of birth, when the baby has had time to recover from the stress of birth.
Page Ref: 674
Cognitive Level: Analyzing
Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum
and Newborn Care
Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple
dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1.
Conduct comprehensive and focused physical, behavioral, psychological,
spiritual, socioeconomic, and environmental assessments of health and illness
parameters in patients, using developmentally and culturally appropriate
approaches. | NLN Competencies: Relationship-Centered Care: Factors that
contribute to or threaten health. | Nursing/Integrated Concepts: Nursing
Process: Assessment
Learning Outcome: 4 Describe the components of a neurologic assessment
and the neurologic/neuromuscular characteristics of the newborn.
MNL LO: 4.2.1 Recognize the timing and components of newborn assessment.
1
Copyright 2016 Pearson Education, Inc.
2) Before the nurse begins to dry off the newborn after birth, which assessment
finding should the nurse document to ensure an accurate gestational rating on
the Ballard gestational assessment tool?
,1. Amount and area of vernix coverage
2. Creases on the sole
3. Size of the areola
4. Body surface temperature
Answer: 1
Explanation: 1. Drying the baby after birth will disturb the vernix and
potentially alter the gestational age criterion. The nurse should document the
amount and areas of vernix coverage before drying the newborn.
,Page Ref: 674
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum
and Newborn Care
Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple
dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1.
Conduct comprehensive and focused physical, behavioral, psychological,
spiritual, socioeconomic, and environmental assessments of health and illness
parameters in patients, using developmentally and culturally appropriate
approaches. | NLN Competencies: Relationship-Centered Care: Factors that
contribute to or threaten health. | Nursing/Integrated Concepts: Nursing
Process: Assessment
Learning Outcome: 2 Summarize the components of a systematic physical
newborn assessment and the significance of normal variations and abnormal
findings.
MNL LO: 4.2.1 Recognize the timing and components of newborn
assessment.
2
Copyright 2016 Pearson Education, Inc.
3) A new mother is concerned about a mass on the newborns head. The nurse
assesses this to be a cephalohematoma based on which characteristics?
Note: Credit will be given only if all correct choices and no incorrect choices
are selected.
Select all that apply.
1. The mass appeared on the second day after birth.
2. The mass appears larger when the newborn cries.
3. The head appears asymmetrical.
4. The mass appears on only one side of the head.
5. The mass overrides the suture line.
Answer: 1, 4
Explanation: 1. A cephalohematoma is a collection of blood resulting from
ruptured blood vessels between the surface of a cranial bone and the
, periosteal membrane. These areas emerge as defined hematomas between the
first and second days.
4. Cephalohematomas can be unilateral or bilateral, but do not cross the
suture lines.
Page Ref: 683
Cognitive Level: Understanding
Client Need/Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple
dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1.
Conduct comprehensive and focused physical, behavioral, psychological,
spiritual, socioeconomic, and environmental assessments of health and illness
parameters in patients, using developmentally and culturally appropriate
approaches. | NLN Competencies: Relationship-Centered Care: Factors that
contribute to or threaten health. | Nursing/Integrated Concepts: Nursing
Process: Assessment
Learning Outcome: 2 Summarize the components of a systematic physical
newborn assessment and the significance of normal variations and abnormal
findings.
MNL LO: 4.2.1 Recognize the timing and components of newborn assessment.
3
Copyright 2016 Pearson Education, Inc.
4) The nurse is using the New Ballard Score to assess the gestational age of a
newborn delivered 4 hours ago. The infants gestational age is 33 weeks based
on early ultrasound and last menstrual period. The nurse expects the infant to
exhibit which of the following?
1. Full sole creases, nails extending beyond the fingertips, scarf sign showing
the elbow beyond the midline
2. Testes located in the upper scrotum, rugae covering the scrotum, vernix
covering the entire body
3. Ear cartilage folded over, lanugo present over much of the body, slow
recoil time
4. 1 cm breast bud, peeling skin and veins not visible, rapid recoil of legs and
