A nurse is teaching a new mother about normal variations in newborns.
Which of the following statements by the mother indicates an understanding of the teaching?
“Milia are caused by blocked sebaceous glands and will go away on their own.”
“Mongolian spots are a sign of bruising and should be reported to the provider.”
“Head circumference should be about 5 cm smaller than the chest circumference.”
“Fontanelles should be sunken and firm to indicate adequate hydration.”.
The Correct Answer is A
Milia are caused by blocked sebaceous glands and will go away on their own. They are tiny, white bumps on a newborn’s nose, cheeks, chin and forehead.
Choice B is wrong because Mongolian spots are not a sign of bruising and should not be reported to the provider. They are blue or purple-colored splotches on the baby’s lower back and buttocks that are caused by a concentration of pigmented cells. They are more common in dark-skinned babies of all races and usually fade by age 5.
Choice C is wrong because head circumference should be about 2 cm larger than the chest circumference, not smaller.
A smaller head circumference may indicate a problem with brain development.
Choice D is wrong because fontanelles should be flat and soft to indicate adequate hydration. Sunken and firm fontanelles may indicate dehydration or increased intracranial pressure. Fontanelles are the soft spots on a baby’s head where the skull bones have not yet fused together.
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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