A nurse is performing the physical maturity test on a newborn using the New Ballard Scale.
What characteristic would the nurse assess?
Skin thickness and presence of lanugo
Flexion in different positions
Creases on the bottom of feet
Scrotum development.
The Correct Answer is B
Flexion in different positions. The New Ballard Scale is a scale that estimates the gestational age of a newborn infant based on physical and neuromuscular characteristics. Flexion in different positions is one of the six neuromuscular signs that are assessed using the scale. The other neuromuscular signs are square window, arm recoil, popliteal angle, scarf sign, and heel to ear.
The other statements are wrong because:
Skin thickness and presence of lanugo are physical signs, not neuromuscular signs. They are also assessed using the New Ballard Scale, along with plantar surface, breast, eye/ear, and genitals.
Creases on the bottom of feet are part of the plantar surface assessment, which is a physical sign, not a neuromuscular sign.
Scrotum development is part of the genital assessment, which is a physical sign, not a neuromuscular sign.
The New Ballard Scale can be used up to 4 days after birth, but usually within the first 24 hours. The scale is accurate only within plus or minus 2 weeks. The total score determines the gestational maturity in weeks.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Place the newborn on the mother’s chest after delivery.This is because skin-to-skin contact between mother and baby promotes bonding and attachment, which are essential for the baby’s emotional and psychological development.Skin-to-skin contact also helps regulate the baby’s body temperature, heart rate, breathing and blood sugar levels.
Choice B is wrong because wrapping the newborn in a blanket reduces the skin-to-skin contact and may interfere with the bonding process.The father can also bond with the baby by holding him or her against his own skin.
Choice C is wrong because placing the newborn in an isolette separates the baby from the mother and prevents close interaction and communication.The baby may feel insecure and isolated in an isolette.
Choice D is wrong because dressing the newborn in a gown and hat also reduces the skin-to-skin contact and may delay the initiation of breastfeeding.The baby may also lose more heat through clothing than through direct contact with the mother’s body.
Correct Answer is A
Explanation
Normal finding.
The anterior fontanelle is the soft spot on the top of an infant’s head that allows for brain growth and skull expansion.
It normally feels soft and flat when the infant is lying down, and may bulge slightly when the infant is sitting up or crying due to increased blood flow and pressure.
This is not a sign of any problem and should be documented as a normal finding.
Dehydration is wrong because dehydration would cause the fontanelle to feel sunken or depressed, not elevated. Dehydration can also cause other signs such as dry mouth, decreased urine output, and lethargy.
Increased intracranial pressure is wrong because increased intracranial pressure would cause the fontanelle to feel tense or bulging at all times, not only when sitting up or crying. Increased intracranial pressure can also cause other signs such as vomiting, irritability, seizures, and altered level of consciousness.
Infection is wrong because infection would cause the fontanelle to feel warm or tender, not elevated. Infection can also cause other signs such as fever, rash, poor feeding, and fussiness.
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