A nurse is assisting in collecting data for a gestational age assessment on a newborn. Which of the following should the nurse check during a neuromuscular assessment? (Select all that apply.)
Scarf sign
Arm recoil
Moro reflex
Heel to ear
Popliteal angle
Correct Answer : A,B,C
Choice A rationale: The Scarf sign assesses the range of motion of the newborn's shoulder and elbow joint. It measures the ability of the newborn's arm to be brought across the chest.
Choice B rationale: Arm recoil measures the degree of resistance and recoil of the newborn's arm when it is extended and then flexed against the chest. This reflex provides information about the newborn's muscle tone and neuromuscular maturity.
Choice C rationale: The Moro reflex, also known as the startle reflex, is elicited by a sudden change in the newborn's position or by a loud noise. It involves an initial extension and abduction of the arms, followed by a flexion and adduction. This reflex helps assess the newborn's neurologic and neuromuscular maturity.
Choice D rationale: "Heel to ear" is not a standard neuromuscular assessment used in the gestational age assessment. It may be an incorrect or unclear term.
Choice E rationale: The popliteal angle is not a neuromuscular assessment used in the gestational age assessment. It measures the angle of flexion in the knee joint and is not directly related to neuromuscular maturity
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Related Questions
Correct Answer is C
Explanation
Choice A rationale: The presence of phosphatidylglycerol (PG) in the amniotic fluid is another indicator of fetal lung maturity. The absence of PG is associated with an increased risk of respiratory distress syndrome (RDS) in the newborn.
Choice B rationale: A nonstress test is a test performed during pregnancy to evaluate the fetal heart rate in response to fetal movement. It is not directly related to assessing fetal lung maturity.
Choice C rationale: The L/S ratio is an important indicator of fetal lung maturity. Lecithin and sphingomyelin are two surfactants present in the lungs, and the ratio of these two substances increases as the fetal lungs mature. An L/S ratio of 2:1 or greater is considered an indication of lung maturity and suggests that the newborn should be able to breathe adequately after birth.
Choice D rationale: The biophysical profile (BPP) is a prenatal ultrasound assessment of the fetus, which includes evaluating fetal movements, breathing, heart rate, and amniotic fluid volume. While a BPP of 8 is a reassuring score, it does not provide direct information about fetal lung maturity.
Correct Answer is D
Explanation
Choice A rationale: Applying identification bands is an essential step in newborn care, but it is not the priority immediately after delivery. The nurse should first address the baby's physiological needs, such as drying and maintaining body temperature.
Choice B rationale: Assessing and documenting the Apgar score is important for evaluating the newborn's overall condition and response to delivery, but it is not the priority immediately after delivery.
Choice C rationale: Administering phytonadione (vitamin K) to prevent bleeding disorders in the newborn is essential, but it can be done after drying and stabilizing the baby's body temperature.
Choice D rationale: After ensuring a patent airway, the nurse's priority should be to dry the newborn. Drying the newborn is important for maintaining body temperature and preventing heat loss, especially during the immediate post-delivery period. Wet newborns can lose heat rapidly through evaporation, so drying the baby helps prevent hypothermia and stabilize the baby's body temperature.
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