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","B","C","E"]

Explanation

A. Discard unused formula in used bottle after 2 hours:Once a baby has started drinking from a bottle, bacteria from the baby’s mouth can contaminate the formula. Any leftover formula should be discarded after 2 hours to prevent bacterial growth and reduce the risk of infection.

B. Never prop a bottle:Propping a bottle can lead to choking, ear infections, and dental issues (such as baby bottle tooth decay). Babies should always be held upright during feedings.

C. Formula is available in three forms:Infant formula is available in three types:Ready-to-feed (no mixing needed),Liquid concentrate (mix with water),Powdered formula (mix with water).

E. Store prepared bottles in the refrigerator:If formula is prepared in advance, it must be stored in the refrigerator (≤ 4°C or 40°F) and used within 24 hours to prevent bacterial growth.

Incorrect Answer:

D. Warm the bottle in the microwave:Microwaving heats unevenly, creating hot spots that can burn the baby’s mouth. Instead, warm bottles by placing them in warm water for a few minutes and always test the temperature on the wrist before feeding.

A. Nevus flammeus B. Cephalhematoma C. Molding D. Caput succedaneum

Correct Answer is B

Explanation

Choice A reason:

Nevus flammeus is a port-wine stain, a type of birthmark that is present at birth and does not fade over time. It is caused by a malformation of capillaries in the skin and appears as a reddish-purple patch. It can occur anywhere on the body but is not associated with swelling or suture lines.

Choice B reason:

Cephalhematoma is a collection of blood under the periosteum of the skull bone, usually caused by trauma during delivery. It appears as a swollen area on the head that does not cross the suture line because it is limited by the boundaries of the bone. It usually resolves within a few weeks or months without treatment.

Choice C reason:

Molding is the temporary change in the shape of the newborn's head due to the pressure of the birth canal during delivery. It results in an elongated or cone-shaped head that may cross the suture line. It usually resolves within a few days as the skull bones return to their normal position.

Choice D reason:

Caput succedaneum is a localized swelling of the scalp, usually caused by pressure from the cervix or vacuum extraction during delivery. It appears as a soft, puffy area on the head that crosses the suture line because it is not limited by the bone. It usually resolves within a few days without treatment.

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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.)

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