Grunting, nasal flaring, retractions, or central cyanosis indicate respiratory distress and must be reported now.
Before you read
Test yourself first: 5 questions
Question 1 of 5
During the newborn assessment, the nurse strokes the cheek and the infant turns the head toward the stimulus and opens the mouth. Which reflex is the nurse eliciting?
Answer: B. The rooting reflex is elicited by stroking the cheek or corner of the mouth; the infant turns toward the stimulus and opens the mouth, which aids feeding. It normally disappears by about 3-4 months. The sucking, Moro (startle), and Babinski (toe fanning) reflexes are distinct responses.
Question 2 of 5
A nurse assesses a newborn at 1 minute of life: heart rate 110, slow irregular respirations with a weak cry, some flexion of extremities, grimace with suctioning, and a pink body with blue hands and feet. What is this newborn's Apgar score?
Answer: B. Apgar scores each of 5 signs 0-2. HR over 100 = 2; slow irregular weak cry = 1; some flexion = 1; grimace = 1; acrocyanosis (blue extremities, pink body) = 1, for a total of 6. A score of 4-6 is moderately depressed and warrants continued support; 7-10 is reassuring.
Question 3 of 5
A newborn's heel-stick glucose is 38 mg/dL at 1 hour of age and the infant is jittery. What is the nurse's FIRST action?
Answer: B. A jittery infant with glucose below 40-45 mg/dL is symptomatic hypoglycemic. The first intervention for a symptomatic but feeding-capable newborn is to feed (breast or formula) to raise glucose, then recheck. Severe or unresponsive cases require IV dextrose. Jitteriness that resolves with feeding distinguishes hypoglycemia from seizures.
Question 4 of 5
A nurse obtains a heel-stick blood glucose of 32 mg/dL on a 2-hour-old large-for-gestational-age newborn who is jittery. What is the priority intervention?
Answer: A. A blood glucose below 40 mg/dL in a symptomatic newborn indicates hypoglycemia. The priority is to feed the infant (breast or formula) promptly to raise glucose, then recheck. LGA infants of diabetic mothers are at high risk. Severe or persistent cases may need IV dextrose.
Question 5 of 5
A nurse is performing a neurologic assessment using the Glasgow Coma Scale (GCS) on a client after a stroke. Which response would receive the LOWEST (most impaired) score in the eye-opening category?
Answer: A. On the Glasgow Coma Scale, eye-opening is scored from 4 (spontaneous) down to 1 (no eye opening). No eye opening to any stimulus is the lowest score of 1. Opening spontaneously scores 4, opening to voice scores 3, and opening to pain scores 2. A lower total GCS indicates more severe impairment.
Keep the streak going with more questions like these, each with a full rationale.
What is newborn assessment?
It includes vital signs, measurements, reflexes, and a head-to-toe exam. Maintaining airway, temperature, and glucose are the immediate priorities.
Key points to remember
- Normal newborn vitals: heart rate 110 to 160 bpm, respirations 30 to 60 breaths/min, axillary temperature 97.7 to 99.5 F (36.5 to 37.5 C).
- Expected weight is 2,500 to 4,000 g; a 5 to 10 percent weight loss in the first days is normal.
- Primitive reflexes (Moro, rooting, sucking, palmar/plantar grasp, Babinski, stepping, tonic neck) should be present and symmetric.
- Acrocyanosis, milia, Mongolian spots, vernix, lanugo, and molding are normal newborn findings.
- Newborns are obligate nose breathers and lose heat rapidly through radiation, evaporation, conduction, and convection.
Nursing priorities
- Dry the newborn immediately and place skin-to-skin or under a radiant warmer to prevent cold stress.
- Suction the mouth before the nose to maintain a patent airway.
- Administer vitamin K IM to prevent hemorrhagic disease and erythromycin eye ointment to prevent ophthalmia neonatorum.
- Perform measurements, full head-to-toe exam, and gestational age assessment.
- Verify two identification bands match the mother and ensure security measures against abduction.
Labs & values
Patient teaching
- Always place the baby on the back to sleep on a firm flat surface with no soft bedding to reduce SIDS risk.
- Feed every 2 to 3 hours; 6 or more wet diapers a day indicates adequate intake.
- Support the head and never leave the baby unattended on a raised surface.
Red flags: report now
- Grunting, nasal flaring, retractions, or central cyanosis indicate respiratory distress and must be reported now.
- Jitteriness, lethargy, poor feeding, or temperature instability may signal hypoglycemia or sepsis.
- A heart rate persistently below 100 or above 160 at rest, or apnea over 20 seconds, requires immediate evaluation.
References
Clinical references for this topic
