Which tool provides the best assessment of neurological and physical maturity correlating with gestational age of the newborn that the nurse can perform after birth.
Apgar score.
Ballard score.
Phenylketonuria screening results.
Length and weight measurements.
The Correct Answer is B
Choice A rationale
The Apgar score is a rapid method, performed at one and five minutes after birth, to quickly assess the newborn's immediate adjustment to extrauterine life by evaluating five signs: heart rate, respiratory effort, muscle tone, reflex irritability, and color. It is an index of immediate postnatal transition and resuscitation need, but it does not correlate with or assess the infant's gestational age or physical maturity.
Choice B rationale
The Ballard score, a common assessment tool, systematically evaluates both the neuromuscular maturity (e.g., posture, square window, scarf sign) and physical maturity (e.g., skin texture, lanugo, plantar creases, breast development, ear cartilage, and genitalia) of a newborn. The total score is then used to estimate the infant's gestational age with a high degree of correlation, which is vital for providing appropriate clinical care.
Choice C rationale
Phenylketonuria (PKU) screening is a metabolic test performed as part of the newborn screening panel, usually after 24 hours of feeding, to detect the absence of the enzyme phenylalanine hydroxylase. This test is crucial for early detection of a treatable inborn error of metabolism but has no correlation with or utility in assessing the physical or neurological maturity of the newborn or estimating gestational age.
Choice D rationale
Length and weight measurements, along with head circumference, are standard anthropometric assessments used to track growth and compare the newborn's size relative to its estimated gestational age (e.g., small, appropriate, or large for gestational age). While important for growth monitoring, these measurements alone do not provide a comprehensive assessment of neurological or physical maturity for precise gestational age estimation. —.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Determining the child's specific vocabulary for body functions and feelings is essential to facilitate effective communication and reduce anxiety during hospitalization. Children with Down syndrome may have delayed or limited expressive language skills, and understanding their individual communication patterns is a foundational nursing action.
Choice B rationale
Assessing hearing and visual capabilities is a critical step because children with Down syndrome have an increased incidence of sensory deficits, such as conductive hearing loss and refractive errors. Identifying these deficits allows the nurse to tailor communication and safety measures to the child's specific sensory needs.
Choice C rationale
Encouraging parents to leave the child alone is contraindicated because children with Down syndrome, like most hospitalized children, benefit greatly from the presence of their primary caregivers to feel secure and reduce separation anxiety. Parental presence promotes emotional well-being and facilitates communication.
Choice D rationale
Maintaining the child's usual meal times is an appropriate and supportive action that promotes a sense of normalcy and control for the child in the unfamiliar hospital setting. Consistency in routines, including feeding schedules, helps minimize anxiety and encourages adequate nutritional intake.
Correct Answer is A
Explanation
Choice A rationale
Using over-the-counter vasoconstrictor eye drops like Visine (tetrahydrozoline) in an infected eye is incorrect and would indicate a need for further teaching. These drops can mask the signs of infection, potentially delay appropriate treatment, and may cause rebound redness or irritation. The primary treatment for bacterial conjunctivitis involves prescribed antibiotic drops or ointment, which should be used instead of symptomatic drops.
Choice B rationale
Washing hands immediately after caring for the child is a crucial intervention and indicates appropriate understanding of infection control. Bacterial conjunctivitis is highly contagious, and meticulous hand hygiene is the most effective measure to prevent the transmission of the infection from the child's eyes to others or to the child's unaffected eye.
Choice C rationale
Encouraging the son to avoid touching his eyes is a correct and vital instruction for managing bacterial conjunctivitis. Touching the infected eye promotes autoinoculation of the unaffected eye and is the primary mechanism for transferring the contagious bacteria to surfaces or other individuals, thus spreading the infection.
Choice D rationale
Using a warm compress to help loosen crust that accumulated on the eyelid overnight is a correct and appropriate comfort measure. The heat and moisture help soften and remove the dried discharge (crusts) that accumulate in bacterial conjunctivitis, making it easier for antibiotic drops to penetrate and for the child to open their eye comfortably.
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