A nurse is examining the eyes of a newborn who was born at 38 weeks of gestation.
Which of the following findings should the nurse expect?
Absence of red reflex
Presence of subconjunctival haemorrhages
Inability to track objects
Unequal pupil sizes
The Correct Answer is B
Presence of subconjunctival haemorrhages.
Subconjunctival haemorrhages are small blood spots on the white part of the eye that is caused by pressure during delivery. They are harmless and usually disappear within a few weeks.
Choice A is wrong because the absence of a red reflex is a sign of a serious eye problem, such as a cataract or retinoblastoma.
The red reflex test is done by shining a light into the baby’s eyes and looking for a red reflection from the retina. It is part of the newborn physical screening examination.
Choice C is wrong because the inability to track objects is not expected in a newborn. Babies can usually follow objects with their eyes by 2 to 3 months of age.
Choice D is wrong because unequal pupil sizes can indicate a neurological problem or an eye injury. Pupil sizes should be checked and measured during the newborn physical examination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The anterior fontanelle is bulging and tense when the newborn cries.This is an abnormal finding that should be reported to the provider as it may indicate increased intracranial pressure or intracranial and extracranial tumors.
Choice A is wrong because the anterior fontanelle is normally diamond-shaped and 2 cm wide.
Choice B is wrong because the posterior fontanelle is normally triangular and 0.5 cm wide.
Choice D is wrong because the posterior fontanelle normally closes by 8 weeksand may not be palpable at six weeks.
Correct Answer is ["A","B","C","E"]
Explanation
The correct answer is choice A, B, C and E.The New Ballard Scale is a scale that estimates the gestational age of a newborn infant based on physical and neuromuscular characteristics.The physical characteristics include skin texture, lanugo, plantar surface, breast tissue, eye/ear and genitals.The neuromuscular characteristics include posture, square window, arm recoil, popliteal angle, scarf sign and heel to ear.
The nurse should evaluate all these characteristics and assign a score for each one.The total score determines the gestational maturity in weeks.
Choice D is wrong because hair pattern is not one of the physical characteristics used in the New Ballard Scale.
Hair pattern may vary depending on genetic factors and is not a reliable indicator of gestational age.
The normal ranges for each characteristic are given in the table below:
|
Characteristic |
Score |
-1 |
0 |
1 |
2 |
3 |
4 |
5 |
|
Posture |
Extended |
Flexed |
Full flexion |
|||||
|
Square window |
>90° |
90° |
60° |
45° |
||||
|
Arm recoil |
Extended |
Slight flex |
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