In newborn babies which parameter is measured through the Apgar score Quizlet

The AGPAR score is based on which 5 parameters?
A. heart rate, respiratory effort, temperature, tone, and color
B. heart rate, muscle tone, reflex irritability, respiratory effort, and color
C. heart rate, breaths per minute, irritability, reflexes, and color
D. heart rate, breaths per minute, irritability, tone, and color

Which measurements were most likely obtained from a normal newborn born at 38 weeks to a healthy mother with no maternal complications?
A. weight = 2000 g, length = 17 inches (43 cm), head circumference = 32 cm, and chest circumference = 30

B. weight = 2500 g, length = 18 inches (46 cm), head circumference = 32 cm, and chest circumference = 30 cm

C. weight = 3500 g, length = 20 inches (51 cm), head circumference = 34 cm, and chest circumference = 32 cm

D. weight = 4500 g, length = 22 inches (56 cm), head circumference = 36 cm, and chest circumference = 34 cm

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Posture: With maturation the newborn are coiled into flexion. If born early or sick (32 weeks or lower) babies will lay passively in extension. 33-34 you get frogging because of mm tone develops caudal to cephalic.

Square window: flexibility increases with maturation at the wrist. Wrist angle if inutero their hand will touch forearm (hand and foot get increases ROM because of tuck in-utero).

Recoil: straightening arms will recoil into flexion.

Popliteal angle decreases as the baby matures because mm get tighter.

Scarf sign: (must know) hold baby's head in midline and see how far elbow will go across midline. Without tone it will go way across midline and when tone develops they will not be able to come past midline.

Heel to ear shows tone as they mature they can no longer put their legs to their heads.

Add up score: Higher the score the higher the maturity.

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Terms in this set (57)

A nurse assigns an Apgar score to a newborn baby at 5 minutes after delivery. Which parameter should the nurse recognize as an abnormal finding?

Apical pulse is less than 100 beats per minute

A nurse obtains Apgar scores on a newborn at 1 minute after birth. When should the nurse perform the next Apgar score?

5 minutes

During an assessment of a newborn, the nurse notes that the head of the baby's right femur slips out of the hip socket. How should the nurse document this finding?

Positive Barlow sign
[A feeling of the head of the femur slipping out of the hip socket is a positive Barlow sign. The Moro and stepping reflexes are not assessed by moving the baby's legs at the hip joints. The Harlequin sign is a skin marking.]

A nurse inspects the anus of a newborn. Which of the following findings should be referred immediately to a specialist?

Imperforate anus

A newborn appears to be in respiratory distress with a respiratory rate of 70 breaths/min, nasal flaring, and intercostal retractions. The newborn has a temperature of 37.2°C (98.9°F;) and a pulse rate of 190 beats/min. What is the normal range for a newborn's heart rate?

120-160 beats/min

A mother of a newborn expresses concern to the nurse that her baby's eyes appear blue but both she and the baby's father have brown eyes. How should the nurse respond to the mother's concern?

"Permanent eye color will appear about 9 months of age."

During examination of a newborn, the nurse touches the upper lip so that the newborn will move the head towards the stimulated area and open the mouth. What reflex is the nurse eliciting from this action?

Rooting
[The nurse is eliciting the rooting reflex in the baby. The sucking reflex is assessed by placing a nipple in the newborn's mouth. The plantar reflex is assessed by touching the ball of the newborn's foot so that the toes curl downwards tightly. The palmar reflex is elicited by pressing the fingers against the palmar surface of the newborn's hands from the ulnar side.]

Which procedure demonstrates correct placement of a tape measure by a nurse when measuring the chest circumference of a 12-month-old infant?

Nipple line

A nurse assesses a newborn with bruising on the head. How should the nurse document this finding?

Ecchymoses
[Ecchymosis is bruising of the skin. The white, cheesy substance seen on the skin of the infant, especially in the folds of the skin, is vernix caseosa, which is normal in the newborn. Lanugo is the fine, downy hair that disappears after 2 weeks of life. Erythema toxicum is the rash seen in the first few days after the birth.]

A nurse is assessing a 1-month-old infant with a distended abdomen. Which of the following conditions would most likely explain this finding?

Pyloric stenosis

A client brings in her 5-month-old for a "stuffy nose." While the infant is being examined, the parent states, "Why does my baby still have a hard time holding his head up?" What does the nurse understand about this milestone?

The infant should be able to hold the head up without support by 4 months of age.

A mother brings her 2-month-old infant to the health care facility with a high temperature. Which action by the nurse demonstrates the proper way to safely measure the rectal temperature in the baby?

Insert the thermometer no more than 2 cm into the rectum.
[The rectal temperature is most accurate. The nurse should insert the lubricated rectal thermometer no more than 2 cm into the rectum when taking the rectal temperature. The baby should be in the supine position and not in the prone position when assessing rectal temperature. The newborn's legs should be bent at the hip, not at the knees. Temperature registers in 3 to 5 minutes, not 1 minute, on a rectal thermometer.]

A mother visits the clinic with her 2-month-old son for a routine visit. The mother has been bottle feeding the infant and asks the nurse, "When can I start giving him solid foods?" The nurse should instruct the mother that solid foods can be introduced when the infant is

4 to 6 months old.

During examination of a newborn, the nurse presses her finger against the newborn's palm and the newborn grasps the finger. What reflex is the nurse eliciting from this action?

Palmar

A new mother wants to give her baby honey. The nurse tells her that it is potentially dangerous to do this. Why is this practice potentially dangerous?

Honey is a known reservoir for the botulism bacterium

A group of students is preparing a class presentation on infant sleeping and Sudden Infant Death Syndrome. The presentation would include which of the following?

Teach parents about placing the baby on his back to sleep.

On inspecting a newborn's breasts, the nurse notes that they are enlarged and engorged, with a white liquid discharge. The infant's mother is concerned about it. Which of the following should the nurse tell the mother regarding this finding?

It is due to the influence of the maternal hormones and should resolve in a few days.

During examination of a newborn, the nurse strokes the lateral edge and ball of the newborn's foot so that the toes fan. What reflex is the nurse eliciting from this action?

Babinski

The nurse is performing a routine newborn assessment and gently strokes the cheek of the baby. The newborn turns toward the stroke and opens the mouth. What is this reflex called?

Rooting reflex

To obtain the most accurate temperature on an infant, a nurse should use which method?

Rectal

A nurse assesses a newborn and finds a white, cheesy substance on the infant's skin, especially within the folds of the skin. How should the nurse document this finding?

Vernix caseosa

A nursery nurse is assessing the neurologic status of a newborn. What area would the nurse be assessing?

Reflexes

A nurse is providing care to a mother and her newborn (12 hours old). The nurse observes a yellowing tint of the newborn's skin. The mother asks, "Is it okay that my baby is yellow?" What is the best response by the nurse?

"Yellow skin is common in newborns; it will clear up with ultraviolet light therapy."
[Yellow skin (jaundice) in newborns is common. It is due to immature liver function. Ultraviolet light (artificial or sunlight) will help lower bilirubin levels. Not all newborns have jaundice; if a newborn develops jaundice within 24 hours after birth it may indicate hemolytic disease, but the nurse would not alarm the client by stating this until further assessments were conducted. Telling the client not to worry about it is nontherapeutic communication (false reassurance). Until further assessments are completed, the nurse would not know if it will clear up on its own without treatment.]

A nurse auscultates the bowel sounds of a 1-month-old. Which of the following findings should warrant further assessment by the nurse?

Presence of marked peristaltic waves

A mother brings her 2-month-old to the clinic for a well-baby check-up. The mother expresses concern that the infant is constantly sucking on their hand or any object they can get their hands on. What is the best response by the nurse?

"This is a normal developmental activity for an infant."
[According to Freud's theory on psychosexual development, newborns and infants (birth to 18 months) are in the oral stage of development. According to Freud's theory, the erogenous zone is the mouth; in this stage the newborn/infant will suck, swallow, chew, and bite for pleasure and to explore their world. Telling the mother to use a pacifier does not answer the mother's concerns and it is a poor communication technique to tell the client what they should do. It is normal for an infant to put their hands in their mouth, so washing the baby's hands frequently is not necessary and may lead to abnormal dryness; infants' hands only need to be washed if their hands become contaminated with a foreign substance, an animal, or another child. Asking if the home has been childproofed yet does not answer the mother's concerns.]

The student nurse reports that the breath sounds of an infant are loud and harsh. How should the nurse best respond?

"Breath sounds in infants will be louder and harsher due to a thinner chest wall"

A nurse assesses a newborn and finds fine, downy hair all over the newborn's skin. How should the nurse document this finding?

Lanugo

The nurse learns that a new mother was upset after hearing about being pregnant and did not look forward to the birth of the baby. On what should the nurse focus when assessing the mother and the baby?

Emotional attachment

The nurse is preparing to inspect a newborn's inner ear with an otoscope. The nurse should pull the pinna

Down and Back.
[Because an infant's external canal is short and straight, pull the pinna down and back.]

A nurse performs, measures, and documents the findings of the initial newborn assessment. Which data should the nurse recognize as an abnormal finding in the newborn?

Weight of 2000 g

Which action by the nurse demonstrates the correct technique of assessing for the popliteal angle?

Flex thigh on top of the abdomen

A nurse assesses a newborn of African American descent and observes a bluish-pigmented area on the sacrum. The nurse recognizes this as what type of skin variation?

Slate gray nevus

Normal breathing pattern for a full-term infant may include

abdominal/chest breathing movements at a rate of 30 to 60 breaths/minute.

A parent tells the nurse, "Sometimes when the baby won't stop crying, I put a little bit of honey in the warm formula. He seems to like it and it soothes him." What is the primary concern with giving honey to infants?

Honey can cause infant botulism.

A newborn is being assessed at 1 minute after birth. A score that indicates the newborn is adapting well to the extrauterine environment is in what range?

7 to 10

A nurse is evaluating reflexes in a newborn. The nurse gently strokes the cheek, and the newborn turns toward the stimulus and opens the mouth. What reflex is the nurse testing?

Rooting

The nurse is assessing a 4-month-old baby. Which observation indicates that the child is developing gross motor skills?

Absence of head lag

A mother brings her 2-month-old infant to the health care clinic because she has noticed a bulge at the umbilicus that seems to get bigger when the baby cries. That nurse recognizes this as what type of finding?

Umbilical hernia

The mother of a 9-month-old girl calls the clinic. She tells the nurse that her daughter has developed a rash. The nurse asks a series of questions to assess the rash. Why would it be important for the nurse to ask these questions?

Helps pinpoint possible causes

A new mother tells the nurse that the newborn has a small yellow lesion on the hard palate of the mouth and is worried about the baby's ability to suck properly. What should the nurse tell the mother about this finding?

"This is common and will disappear within the first few weeks."
[This finding is common in newborns and is called an Epstein pearl. It is found on the hard palate and gums and presents as a small, yellow-white retention cyst that disappears within the first few weeks of life. Sucking tubercles are common in infants on the upper lip but do not occur from improper sucking. This is not an infection, thus no culture is needed. A cleft palate usually occurs together with a cleft lip. A cleft is a fissure, opening, or gap. It is the nonfusion of the body's natural structures that form before birth.]

Which action by the nurse demonstrates the correct technique to elicit Ortolani's maneuver?

Abduct the legs and move the knees outward

On assessing a newborn, a nurse observes a separation of the abdominal muscles. That nurse recognizes the underlying case of this condition is which of the following?

Immature abdominal muscles

When performing an assessment of a 2-month-old infant, the nurse turns the baby's head to the side while the infant is supine. The arm and leg extend on the side to which the face is pointed. The contralateral arm and leg flex, forming the classic fencing position. What is the name of this reflex?

Tonic neck reflex

While assessing a newborn infant, the nurse observes yellow-white retention cysts in the newborn's mouth. The nurse should explain to the infant's parents that these spots are usually indicative of

Epstein pearls.
[Epstein's pearls—small, yellow-white retention cysts on the hard palate and gums—are common in newborns and usually disappear in the first weeks of life.]

A nurse performs an Apgar assessment on a newborn at 1 minute with a score of 7 and at 5 minutes with a score of 10. What action should the nurse take?

Epstein pearls.

The Moro reflex is

a response to sudden stimulation or an abrupt change in position.

The mother of a newborn has struggled to effectively breastfeed her daughter. The mother has received instruction from a lactation specialist on proper breastfeeding techniques, but the baby will not latch on. She has decided to bottle feed the baby at least for now. Also, when assessing the infant's musculoskeletal system, the nurse found unequal gluteal folds and limited hip abduction. Which of the following should be the priority nursing conclusion?

RC: Hip displacement

What should a nurse keep in mind when palpating for the testes in a male infant?

Touch or cold may pull the testicles back into the inguinal canal

Which action by the nurse demonstrates the correct technique to assess the anus?

Spread the buttocks with gloved hands.

How should a nurse test visual acuity in an infant of 6 weeks of age?

Watch to see if the infant can follow a moving object

A mother of a newborn expresses concern that the anterior fontanelle is palpable when the newborn cries. What is the best response by the nurse?

"The anterior fontanelle will close between 12 and 18 months."

A nurse auscultates the chest of a newborn. The nurse hears breath sounds that are loud and harsh. Which of the following does this finding most likely indicate?

Normal
[Breath sounds may seem louder and harsher in young children because of their thin chest walls. Diminished breath sounds suggest respiratory disorders such as pneumonia or atelectasis. Stridor (inspiratory wheeze) is a high-pitched, piercing sound that indicates a narrowing of the upper tracheobronchial tree. Expiratory wheezes indicate narrowing in the lower tracheobronchial tree.]

The nurse is assessing a 1-year-old infant who weighed 3.6 kg (8 lb) at birth. When the nurse prepares to weigh the infant, the nurse anticipates that this infant should weigh approximately

10.8 kg (24 lb).
[Deviation from the wide range of normal weights is abnormal. Compare differences by referencing the growth charts available at http://www.cdc.gov/growthcharts.]

The nurse notes that a sleeping newborn's heart rate is 102 bpm. What action should the nurse take first?

Document the heart rate
[A pulse rate of 100 bpm when the infant is sleeping is considered normal and should be documented. There is no need to apply oxygen, notify the health care provider, or increase the temperature in the incubator.]

A nurse checks a newborn for the Scarf sign. What should the nurse see if the newborn is full term?

Elbow position is less than midline of chest
[To assess the Scarf sign, a nurse should lift the arm across the chest towards the opposite shoulder until resistance is met. In a full-term infant, the elbow position should be less than the midline of the chest. If the wrist reaches to opposite shoulder, the infant is preterm. Arm quickly recoils to a flexed state is seen when testing for arm recoil. Wrist resistance is met at angle less than 30 degrees is seen when testing the square window sign.]

During a physical examination a 4-month old baby begins to cry. Which assessment finding should the nurse expect at this time?

bulging anterior fontanelle
[Increased intracranial pressure produces a bulging, full anterior fontanelle and is seen when a baby cries. By age 4 months the posterior fontanelle should be closed. The average heart rate of a 4-month old should be between 80 and 180 beats per minute. The respiratory rate for this baby should be less than 50 breaths per minute.]

A nurse midwife is making a well-baby visit for a 5-month-old infant. The nurse determines delayed development when which of the following is observed?

The infant lacks head control.
[Infants should have head control by 4 months of age. If the infant lacks head control by 6 months, this may indicate cerebral palsy. A positive Babinski reflex (fanning of the toes) is normal up to 2 years in infants. The child seeking comfort from their parent indicates that trust versus mistrust has been achieved according to Erikson's psychosocial development theory. A respiratory rate of 40 breaths/min is normal in infants up to 12 months.]

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Which of the following parameters are measured in determining an Apgar score?

The Apgar score comprises five components: 1) color, 2) heart rate, 3) reflexes, 4) muscle tone, and 5) respiration, each of which is given a score of 0, 1, or 2.

What is an Apgar score list the assessment parameters quizlet?

minutes after birth. The five parameters of the APGAR score include: heart rate, respiratory effort, muscle tone, reflex irritability, and color.

Which is the Apgar score of a newborn in severe distress quizlet?

-A combined Apgar score of 7 or better indicates that the infant is in good physical condition. -If the score is between 4 and 6, the baby requires assistance in establishing breathing and other vital signs. -If the score is 3 or below, the infant is in serious danger and requires emergency medical attention.

Which assessments are included in evaluating a newborn using the Apgar scoring system quizlet?

Apgar score includes assessment of heart rate, reflexes, color, respiration, and muscle tone to make a total possible score of 10. Crying is part of the respiratory assessment, but it is not an assessment performed within the Apgar. Meconium present at birth is assessed, but not part of the Apgar scoring system.