The nurse completing a gestational exam using the Ballard assessment tool understands that this assesses which two maturity components?
Physical and Behavioral.
Behavioral and Reflexive.
Neuromuscular and Physical.
Reflexive and Neuromuscular.
The Correct Answer is C
A. The Ballard tool does not assess behavioral maturity directly.
B. The reflexes are part of the neuromuscular system, but the tool assesses both neuromuscular and physical maturity.
C. The Ballard assessment tool evaluates both neuromuscular maturity (such as posture, square window sign, arm recoil) and physical maturity (such as skin, ear form, breast tissue) in neonates to assess gestational age.
D. Reflexes are part of neuromuscular maturity, but the tool combines both neuromuscular and physical components.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Using a whole hand for gentle containment is more appropriate for calming preterm infants.
B. Promoting flexion, not extension, helps mimic the fetal position and provides comfort.
C. A dimly lit environment is preferred for preterm infants to reduce sensory overload.
D. Clustering care reduces stimulation and promotes rest, which is essential for preterm infant development and reducing stress.
Correct Answer is D
Explanation
A. Administering oxygen is unnecessary unless central cyanosis (lips and tongue) is present.
B. An isolette may help with thermoregulation, but swaddling is the more immediate action.
C. Pulse oximetry is unnecessary for peripheral cyanosis.
D. Cyanotic hands and feet (acrocyanosis) are normal in the first 24-48 hours after birth due to immature circulation. Keeping the baby warm by swaddling promotes circulation.
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