Review Normal Variations and Abnormal Findings

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Normal Variations and Abnormal Findings

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Total Questions : 5

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Question 1:

A nurse is assessing a newborn’s fontanelles.

Which of the following findings should the nurse report to the provider?

A. The anterior fontanelle is diamond-shaped and 2 cm wide. B. The posterior fontanelle is triangular and 0.5 cm wide. C. The anterior fontanelle is bulging and tense when the newborn cries. D. The posterior fontanelle is closed and not palpable.

Answer and Explanation

Choice A:

The anterior fontanelle is normally diamond-shaped and 2 cm wide.

Choice B:

The posterior fontanelle is normally triangular and 0.5 cm wide.

Choice C:

This is an abnormal finding that should be reported to the provider as it may indicate increased intracranial pressure or intracranial and extracranial tumors.

Choice D:

The posterior fontanelle normally closes by 8 weeksand may not be palpable at six weeks.

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Question 2:

A nurse is teaching a new mother about normal variations in newborns.

Which of the following statements by the mother indicates an understanding of the teaching?

A. “Milia are caused by blocked sebaceous glands and will go away on their own.” B. “Mongolian spots are a sign of bruising and should be reported to the provider.” C. “Head circumference should be about 5 cm smaller than the chest circumference.” D. “Fontanelles should be sunken and firm to indicate adequate hydration.”.

Answer and Explanation

Choice A:

They are tiny, white bumps on a newborn’s nose, cheeks, chin and forehead.

Choice B:

Mongolian spots are not a sign of bruising and should not be reported to the provider.They are blue or purple-colored splotches on the baby’s lower back and buttocks that are caused by a concentration of pigmented cells.They are more common in dark-skinned babies of all races and usually fade by age 5.

Choice C:

Head circumference should be about 2 cm larger than the chest circumference, not smaller.

A smaller head circumference may indicate a problem with brain development.

Choice D:

Fontanelles should be flat and soft to indicate adequate hydration.Sunken and firm fontanelles may indicate dehydration or increased intracranial pressure.Fontanelles are the soft spots on a baby’s head where the skull bones have not yet fused together.

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Question 3:

A nurse is caring for a newborn who has a temperature of 36.1°C (97°F), heart rate of 140/min, respiratory rate of 50/min, muscle tone of 1, and reflex irritability of 1.

What is the newborn’s APGAR score at 1 minute?

A. 4 B. 5 C. 6 D. 7

Answer and Explanation

Choice A:

A score of 4 would mean that the newborn has a score of 0 for one of the criteria, which is not the case.

Choice B:

The APGAR score is a method of assessing the health of a newborn based on five criteria: appearance (skin color), pulse (heart rate), grimace (reflex irritability), activity (muscle tone), and respiration (breathing rate and effort).

Choice C:

A score of 6 would mean that the newborn has a score of 2 for one of the criteria, which is not the case.

Choice D:

A score of 7 would mean that the newborn has a score of 2 for two of the criteria, which is not the case.

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Question 4:

A nurse is using the New Ballard Scale to assess the gestational age of a newborn.

Which of the following physical characteristics should the nurse evaluate? (Select all that apply.)

A. Arm recoil B. Breast tissue C. Ear form D. Hair pattern E. Skin texture

Answer and Explanation

Choice A:

The New Ballard Scale is a scale that estimates the gestational age of a newborn infant based on physical and neuromuscular characteristics. The physical characteristics include skin texture, lanugo, plantar surface, breast tissue, eye/ear and genitals. The neuromuscular characteristics include posture, square window, arm recoil, popliteal angle, scarf sign and heel to ear.

Choice B:

Choice C:

Choice D:

Hair pattern is not one of the physical characteristics used in the New Ballard Scale.

Choice E:

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Question 5:

A nurse is examining the eyes of a newborn who was born at 38 weeks of gestation.

Which of the following findings should the nurse expect?

A. Absence of red reflex B. Presence of subconjunctival haemorrhages C. Inability to track objects D. Unequal pupil sizes

Answer and Explanation

Choice A:

The absence of a red reflex is a sign of a serious eye problem, such as a cataract or retinoblastoma.

The red reflex test is done by shining a light into the baby’s eyes and looking for a red reflection from the retina.It is part of the newborn physical screening examination.

Choice B:

Subconjunctival haemorrhages are small blood spots on the white part of the eye that is caused by pressure during delivery.They are harmless and usually disappear within a few weeks

Choice C:

The inability to track objects is not expected in a newborn.Babies can usually follow objects with their eyes by 2 to 3 months of age.

Choice D:

Because unequal pupil sizes can indicate a neurological problem or an eye injury.Pupil sizes should be checked and measured during the newborn physical examination.

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Normal Variations and Abnormal Findings

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