A nurse is assisting to collect data for a gestational age assessment on a newborn. Which of the following should the nurse check during a neuromuscular assessment? (Select all that apply.)

Heel to ear

Popliteal angle

Moro reflex

Scarf sign

Arm recoil

Answer and Explanation

Correct Answer : A,B,D,E

Choice A reason:

Heel to ear is a test that measures the flexibility of the newborn's hip and knee joints. The nurse should gently flex the newborn's hip and knee and bring the foot toward the ear on the same side. The closer the foot is to the ear, the higher the score. This test is part of the neuromuscular assessment for gestational age.

Choice B reason:

Popliteal angle is a test that measures the angle of flexion at the knee joint. The nurse should flex the newborn's hip and knee at 90 degrees and then extend the lower leg until resistance is felt. The smaller the angle, the higher the score. This test is also part of the neuromuscular assessment for gestational age.

Choice C reason:

Moro reflex is a test that evaluates the newborn's startle response. The nurse should hold the newborn in a semi-sitting position and then allow the head to fall back slightly. The newborn should extend and abduct the arms and legs, then flex and adduct them. This test is not part of the neuromuscular assessment for gestational age, but rather a reflex assessment for neurological function. •

Choice D reason:

Scarf sign is a test that measures the flexibility of the newborn's shoulder and elbow joints. The nurse should draw one of the newborn's arms across the chest toward the opposite shoulder. The farther the elbow can be moved across the body, the lower the score. This test is part of the neuromuscular assessment for gestational age.

Choice E reason:

Arm recoil is a test that measures the degree of flexion at the elbow joint. The nurse should extend both of the newborn's arms for 5 seconds and then release them. The arms should return to a flexed position quickly and fully. The faster and more complete the recoil, the higher the score. This test is part of the neuromuscular assessment for gestational age.

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Correct Answer is A

Explanation

Choice A reason:

Small for gestational age (SGA) newborns are at risk for respiratory distress syndrome (RDS) and respiratory acidosis because they have immature lungs that produce less surfactant, which is needed to keep the alveoli open and prevent atelectasis. SGA newborns also have less glycogen stores, which can lead to hypoglycemia and impaired oxygen delivery to the tissues.

Choice B reason:

Maternal history of asthma is not a risk factor for RDS or respiratory acidosis in the newborn. Asthma is a chronic inflammatory disorder of the airways that affects the mother, not the fetus. Maternal asthma can cause complications such as preterm labor, preeclampsia, or intrauterine growth restriction, but it does not directly affect the fetal lung development or function.

Choice C reason:

Ventricular septal defect (VSD) is a congenital heart defect that causes a hole in the wall between the ventricles of the heart. This can result in increased pulmonary blood flow and pressure, which can lead to pulmonary edema and heart failure in the newborn. However, VSD does not cause RDS or respiratory acidosis, which are related to lung maturity and surfactant production.

Choice D reason:

Cesarean birth is not a risk factor for RDS or respiratory acidosis in the newborn. Cesarean birth can increase the risk of transient tachypnea of the newborn (TTN), which is caused by delayed absorption of fetal lung fluid. TTN usually resolves within 24 to 48 hours and does not cause a significant acid-base imbalance in the newborn.

A. Temperature B. Respiratory findings C. Serum glucose D. Hematocrit E. White blood cell count F. Hemoglobin G. Heart rate

Correct Answer is ["C","D","F"]

Explanation

Choice A:

Temperature is not a finding that needs to be reported to the provider unless it is abnormally high or low. The normal temperature range for a newborn is 36.5°C to 37.5°C (97.7°F to 99.5°F).

Choice B:

Respiratory findings are not a finding that needs to be reported to the provider unless they indicate respiratory distress or infection. The normal respiratory rate for a newborn is 30 to 60 breaths per minute.

Choice C:

Serum glucose is a finding that needs to be reported to the provider, as it is higher than the normal range for a newborn. The normal serum glucose level for a newborn is usually just under 2 mmol/L (or 25 mg/dL) at birth, and it will rise to over 3 mmol/L (or 60 to 100 mg/dL) within two to three days. A serum glucose level of 130 mg/dL indicates hyperglycemia, which can have various causes and complications.

Choice D:

Hematocrit is a finding that needs to be reported to the provider, as it is lower than the normal range for a newborn. The normal hematocrit level for a newborn is 44% to 64%. A hematocrit level of 35% indicates anemia, which can have various causes and complications.

Choice E:

White blood cell count is not a finding that needs to be reported to the provider, as it is within the normal range for a newborn. The normal white blood cell count for a newborn is 9,000 to 30,000/mm³.

Choice F:

Hemoglobin is a finding that needs to be reported to the provider, as it is lower than the normal range for a newborn. The normal hemoglobin level for a newborn is 14 to 24 g/dL. A hemoglobin level of 9 g/dL indicates anemia, which can have various causes and complications.

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