A nurse is assisting to collect 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.)
Heel to ear
Popliteal angle
Moro reflex
Scarf sign
Arm recoil
Correct Answer : A,B,D,E
Choice A reason:
Heel to ear is a test that measures the flexibility of the newborn's hip and knee joints. The nurse should gently flex the newborn's hip and knee and bring the foot toward the ear on the same side. The closer the foot is to the ear, the higher the score. This test is part of the neuromuscular assessment for gestational age.
Choice B reason:
Popliteal angle is a test that measures the angle of flexion at the knee joint. The nurse should flex the newborn's hip and knee at 90 degrees and then extend the lower leg until resistance is felt. The smaller the angle, the higher the score. This test is also part of the neuromuscular assessment for gestational age.
Choice C reason:
Moro reflex is a test that evaluates the newborn's startle response. The nurse should hold the newborn in a semi-sitting position and then allow the head to fall back slightly. The newborn should extend and abduct the arms and legs, then flex and adduct them. This test is not part of the neuromuscular assessment for gestational age, but rather a reflex assessment for neurological function. •
Choice D reason:
Scarf sign is a test that measures the flexibility of the newborn's shoulder and elbow joints. The nurse should draw one of the newborn's arms across the chest toward the opposite shoulder. The farther the elbow can be moved across the body, the lower the score. This test is part of the neuromuscular assessment for gestational age.
Choice E reason:
Arm recoil is a test that measures the degree of flexion at the elbow joint. The nurse should extend both of the newborn's arms for 5 seconds and then release them. The arms should return to a flexed position quickly and fully. The faster and more complete the recoil, the higher the score. This test is part of the neuromuscular assessment for gestational age.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","F"]
Explanation
Choice A:
Temperature is not a priority finding to report to the provider. The newborn's temperature may vary slightly depending on the environment and the method of measurement. A normal temperature range for a newborn is 36.5°C to 37.5°C (97.7°F to 99.5°F).
Choice B:
Respiratory findings are important to report to the provider because the newborn had a low Apgar score at 1 minute and required positive pressure ventilation and oxygen. The nurse should assess the newborn's respiratory rate, effort, breath sounds, and oxygen saturation. Any signs of respiratory distress, such as tachypnea, grunting, retractions, nasal flaring, or cyanosis, should be reported immediately.
Choice C:
Serum glucose is a critical finding to report to the provider because the newborn is at risk for hypoglycemia due to the abruptio placenta and the emergency cesarean birth. Hypoglycemia can cause neurological damage and seizures in newborns. A normal serum glucose level for a newborn is 40 to 60 mg/dL.
Choice D:
Hematocrit is a significant finding to report to the provider because the newborn may have polycythemia or anemia due to the abruptio placenta and the blood loss during delivery.
Polycythemia can cause hyperviscosity and thrombosis, while anemia can cause hypoxia and shock. A normal hematocrit level for a newborn is 42% to 65%.
Choice E:
White blood cell count is not a priority finding to report to the provider. The newborn's white blood cell count may be elevated due to the stress of birth or a maternal infection. A normal white blood cell count for a newborn is 9,000 to 30,000/mm3.
Choice F:
Hemoglobin is an important finding to report to the provider because the newborn may have polycythemia or anemia due to the abruptio placenta and the blood loss during delivery.
Hemoglobin is the main component of red blood cells that carries oxygen to the tissues. A normal hemoglobin level for a newborn is 14 to 24 g/dL.
Choice G:
Heart rate is a vital finding to report to the provider because the newborn had a non- reassuring fetal heart rate during labor and delivery. The nurse should monitor the newborn's heart rate and rhythm for any signs of bradycardia, tachycardia, or arrhythmias. A normal heart rate range for a newborn is 110 to 160 beats per minute.
Correct Answer is B
Explanation
Choice A reason:
Allowing opportunities for newborn massage is not recommended for preterm newborns, as it can increase their oxygen consumption and energy expenditure. Massage can also cause stress responses, such as increased heart rate, blood pressure, and cortisol levels.
Choice B reason:
Clustering the newborn's care activities is the best way to help the newborn conserve energy, as it minimizes the frequency of handling and stimulation. Clustering care also allows for longer periods of uninterrupted sleep, which is essential for growth and development.
Choice C reason:
Changing the newborn's position every 2 hours is not necessary for preterm newborns, as it can disrupt their sleep and cause them to lose heat. Preterm newborns have limited ability to regulate their body temperature, and frequent position changes can expose them to cold stress.
Choice D reason:
Placing elbow restraints on the newborn is not indicated for preterm newborns, unless they have a specific condition that requires them, such as a cleft lip or palate repair. Elbow restraints can restrict the newborn's movement and cause skin irritation or injury.
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