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 C
Explanation
A. No bowel movement within 12 hours: While concerning, delayed stooling can occur in preterm infants and is not as urgent without additional symptoms like distension or bilious vomiting.
B. Small regurgitation of formula: Regurgitation is a common finding in preterm infants and typically not alarming unless persistent or associated with other symptoms like aspiration.
C. Abdominal distension: This finding may indicate necrotizing enterocolitis (NEC) or an obstruction, both of which are serious conditions requiring prompt medical attention.
D. Uncoordinated suck: This is expected in preterm infants due to immaturity and does not require immediate reporting.
Correct Answer is A
Explanation
A. The nurse should dry the neonate immediately after birth to prevent heat loss, as newborns are at risk for hypothermia.
B. APGAR scoring is typically done 1 and 5 minutes after birth, not every 30 minutes during the 3rd stage of labor.
C. The neonatal assessment is usually performed after the delivery of the placenta, not during the 3rd stage of labor.
D. Blood samples for blood type are typically obtained after the newborn has stabilized, not during the 3rd stage of labor.
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