Report jitteriness, lethargy, poor feeding, or a low glucose reading (hypoglycemia).
Before you read
Test yourself first: 4 questions
Question 1 of 4
A toddler is brought in for a routine visit. Which is the best approach to physical assessment?
Answer: B. Assess least-distressing areas first and the most invasive (ears, mouth) last, allow a parent to hold the child, use play, and explain simply. Restraining the child for a head-to-toe exam from the start increases distress.
Question 2 of 4
Which assessment finding in a 2-hour-old newborn is an EXPECTED normal variation rather than a sign of pathology?
Answer: B. Acrocyanosis (bluish hands and feet with a pink trunk) is a normal finding in the first 24-48 hours due to immature peripheral circulation. Central cyanosis of the lips and trunk, nasal flaring, and grunting all indicate respiratory compromise and are abnormal.
Question 3 of 4
A nurse performs a home-safety assessment for a community-dwelling older adult to prevent falls. Which modification should the nurse recommend?
Answer: B. Removing throw rugs and clutter and ensuring adequate lighting and grab bars are key home modifications that reduce falls. Adding loose rugs, lowering lighting, and removing handrails all increase fall risk.
Question 4 of 4
A newborn has a 1-minute APGAR of 6. The nurse should:
Answer: B. An APGAR of 4–6 indicates moderate distress needing stimulation and support (dry, warm, stimulate, give oxygen as needed) and reassessment at 5 minutes. 7–10 is normal; 0–3 needs resuscitation.
Keep the streak going with more questions like these, each with a full rationale.
What is gestational age assessment?
Determining gestational age helps anticipate risks: preterm infants face respiratory and thermoregulation problems, while post-term and large infants face hypoglycemia and birth trauma. Infants are also classified by birth weight relative to gestational age as SGA, AGA, or LGA.
Key points to remember
- The New Ballard Score combines physical maturity signs (skin, lanugo, plantar creases, breast, ear/eye, genitals) with neuromuscular signs (posture, square window, arm recoil, popliteal angle, scarf sign, heel-to-ear).
- Term is 38-42 weeks; preterm is before 37 weeks and post-term is after 42 weeks.
- Infants are classified as small (SGA), appropriate (AGA), or large (LGA) for gestational age based on weight percentiles.
- Preterm signs include abundant lanugo, few plantar creases, smooth thin skin, and immature/flat ear cartilage.
- SGA and LGA infants and infants of diabetic mothers are at high risk for hypoglycemia after birth.
- Post-term infants may show peeling/cracked dry skin, long nails, and little lanugo or vernix.
Signs & symptoms
- Preterm → smooth soles, soft ear, lanugo
- Term → flexed posture, sole creases
- Post-term → peeling skin, long nails
Nursing priorities
- Perform the gestational age assessment within the first hours after birth while the infant is stable.
- Monitor blood glucose in SGA, LGA, post-term, and infant-of-diabetic-mother newborns.
- Maintain thermoregulation, especially in preterm/SGA infants prone to cold stress.
- Anticipate and observe for complications matched to maturity (respiratory distress in preterm, birth trauma in LGA).
- Promote early feeding to stabilize glucose and support thermoregulation.
Labs & values
Patient teaching
- Explain to parents how maturity rating helps predict and prevent newborn problems.
- Teach signs of hypoglycemia and the importance of early, frequent feeding.
- Instruct on keeping the newborn warm to prevent cold stress.
Red flags: report now
- Report jitteriness, lethargy, poor feeding, or a low glucose reading (hypoglycemia).
- Report temperature instability/cold stress, especially in preterm or SGA infants.
- Report signs of respiratory distress in preterm newborns.
References
Clinical references for this topic
