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 ["A","B","E"]
Explanation
Choice A:
Tremors. This is a sign of hypoglycemia in a newborn because low blood sugar can cause shakiness or jitteriness in the muscles. •
Choice B:
Lethargy. This is a sign of hypoglycemia in a newborn because low blood sugar can cause low energy, poor feeding, or lack of interest in eating.
Choice C:
Hunger. This is not a sign of hypoglycemia in a newborn because low blood sugar can actually reduce the appetite or cause feeding difficulties.
Choice D:
Jaundice. This is not a sign of hypoglycemia in a newborn because jaundice is caused by high levels of bilirubin in the blood, not low levels of glucose.
Choice E:
Weak cry. This is a sign of hypoglycemia in a newborn because low blood sugar can affect the vocal cords and the respiratory system, causing a weak or high-pitched cry.
Correct Answer is B
Explanation
Choice A reason:
Determining maternal well-being is not the purpose of the Bishop's score. The Bishop's score is a pre-labor scoring system to assist in predicting whether induction of labor will be required. It does not measure maternal vital signs, blood tests, or other indicators of maternal well-being.
Choice B reason:
Determining the readiness of the cervix for labor is the purpose of the Bishop's score. The Bishop's score gives points to five measurements of the pelvic examination: dilation, effacement, station, consistency, and position of the cervix. The higher the score, the more favorable or "ripe”. the cervix is for induction of labor.
Choice C reason:
Determining the progress of labor is not the purpose of the Bishop's score. The Bishop's score is used before labor begins to assess the likelihood of a successful induction or a spontaneous preterm delivery. It does not measure contractions, fetal descent, or other indicators of labor progress.
Choice D reason:
Determining the well-being of the fetus is not the purpose of the Bishop's score. The Bishop's score is a cervical assessment tool that does not directly evaluate fetal status. It does not measure fetal heart rate, movement, or biophysical profile.
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