Advanced Health Assessment of the Neonate Q&A with Rationales, Exams of Nursing

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NURSING 7302

Advanced Health

Assessment of the

Neonate

Q & A w/ Rationales

1. You are assessing a 2-day-old neonate who was born at 36 weeks gestation. The neonate has a respiratory rate of 60 breaths per minute, nasal flaring, intercostal retractions, and grunting. What is the most likely diagnosis for this neonate? A) Transient tachypnea of the newborn B) Respiratory distress syndrome* C) Meconium aspiration syndrome D) Pneumonia Rationale: Respiratory distress syndrome (RDS) is caused by a deficiency of surfactant in the lungs, which leads to alveolar collapse and impaired gas exchange. RDS is more common in preterm infants, especially those born before 37 weeks gestation. The clinical manifestations of RDS include tachypnea, nasal flaring, intercostal retractions, grunting, and cyanosis.
2. You are examining a 3-day-old neonate who was born at term with a vaginal delivery. The neonate has jaundice, lethargy, poor feeding, and a high-pitched cry. The total serum bilirubin level is 25 mg/dL. What is the most appropriate intervention for this neonate? A) Phototherapy* B) Exchange transfusion C) Intravenous fluids D) Antibiotics Rationale: Phototherapy is the treatment of choice for neonatal hyperbilirubinemia, which is a condition

speaking during pregnancy and that she was diagnosed with myasthenia gravis. What is the most likely diagnosis for this neonate? A) Congenital myasthenia gravis* B) Congenital hypothyroidism C) Congenital muscular dystrophy D) Congenital botulism Rationale: Congenital myasthenia gravis (CMG) is a rare disorder that results from the transmission of maternal antibodies against acetylcholine receptors to the fetus. Acetylcholine receptors are essential for neuromuscular transmission and muscle contraction. CMG causes weakness and fatigue of the skeletal muscles, especially those involved in sucking, swallowing, crying, and eye movements.

5. You are performing a routine physical examination on a 6 - day-old neonate who was born at term with a vaginal delivery. The neonate has a normal weight, length, and head circumference. However, you notice that the neonate has micrognathia, low-set ears, webbed neck, shield chest, and widely spaced nipples. What is the most likely diagnosis for this neonate? A) Turner syndrome* B) Down syndrome C) Noonan syndrome D) Edwards syndrome Rationale: Turner syndrome (TS) is a genetic disorder that affects only females and is caused by the partial or complete absence of one X chromosome. TS causes

various physical anomalies and developmental delays, such as short stature, ovarian failure, congenital heart defects, and distinctive facial features. Some of the characteristic facial features of TS include micrognathia, low-set ears, webbed neck, shield chest, and widely spaced nipples. B:

1. A nurse is assessing a newborn who was delivered via cesarean section due to suspected macrosomia. Which signs should the nurse prioritize when conducting an advanced health assessment of this neonate? a. Skin color and general appearance b. Heart rate and respiratory effort c. Palpation of fontanels and sutures d. Reflexes and muscle tone Answer: d. Reflexes and muscle tone Rationale: Assessing reflexes and muscle tone in a neonate delivered via cesarean section helps evaluate potential birth injuries, such as brachial plexus or nerve damage, which can affect the newborn's functionality.
2. During an advanced health assessment of a neonate, the nurse notices a high-pitched, shrill cry. Which condition should the nurse suspect in this neonate? a. Hypoglycemia b. Hyperbilirubinemia

Answer: a. Murmurs detected upon auscultation Rationale: The presence of murmurs upon auscultation can be indicative of congenital heart defects. Further evaluation, such as an echocardiogram, is necessary for definitive diagnosis and appropriate intervention.

5. During an advanced health assessment, a nurse observes excessive tearing and absence of a blinking reflex in a neonate. Which condition should the nurse suspect? a. Congenital ptosis b. Facial nerve palsy c. Lacrimal duct obstruction d. Corneal abrasion Answer: b. Facial nerve palsy Rationale: Excessive tearing and absence of a blinking reflex in a neonate may suggest facial nerve palsy, which can result from birth trauma. Early identification and appropriate management are essential to prevent further complications.
6. A nurse is conducting an advanced health assessment of a newborn and observes a palpable midline mass in the lower lumbar region. Which condition should the nurse suspect? a. Spinal cord injury b. Sacral dimple c. Neuroblastoma d. Developmental dysplasia of the hip

Answer: c. Neuroblastoma Rationale: A palpable midline mass in the lower lumbar region can be suggestive of a neuroblastoma. Further diagnostic tests, such as ultrasound and urine catecholamine levels, are essential for accurate diagnosis and appropriate management.

7. During an advanced health assessment, the nurse notices a neonate with a high-pitched diastolic murmur. Which condition is most likely present in this neonate? a. Patent ductus arteriosus b. Aortic stenosis c. Coarctation of the aorta d. Ventricular septal defect Answer: b. Aortic stenosis Rationale: A high-pitched diastolic murmur is commonly associated with aortic stenosis in neonates. This condition involves narrowing of the aortic valve, resulting in restricted blood flow from the left ventricle.
8. During an advanced health assessment, a nurse notes yellowish discoloration of a neonate's sclera. Which condition should the nurse suspect? a. Physiological jaundice b. Biliary atresia c. Hypothyroidism d. Hemolytic disease of the newborn

Rationale: A specialized cleft palate nipple is designed to accommodate an infant with a cleft lip and palate, ensuring proper suction and reducing the risk of aspiration during feeding.

11. A nurse is assessing a neonate for signs of neonatal sepsis during an advanced health assessment. Which finding requires immediate action? a. Low-grade fever b. Increase in immature neutrophils c. Mildly elevated C-reactive protein levels d. Poor perfusion and tachycardia Answer: d. Poor perfusion and tachycardia Rationale: Poor perfusion and tachycardia indicate that the neonate is in a critical condition, potentially progressing to septic shock. Immediate intervention, such as blood culture collection and initiating antibiotic therapy, is crucial.
12. During an advanced health assessment, the nurse assesses a neonate with omphalocele. Which intervention should the nurse prioritize? a. Applying a sterile, saline-soaked dressing over the omphalocele b. Encouraging the parents to touch the exposed organs c. Administering a daily dose of folic acid supplement d. Promoting kangaroo care and skin-to-skin contact Answer: a. Applying a sterile, saline-soaked dressing over the omphalocele

Rationale: Applying a sterile, saline-soaked dressing over the omphalocele helps protect the exposed organs and prevents infection. This intervention should be initiated promptly after birth.

13. A nurse is assessing a neonate for signs of meconium aspiration syndrome during an advanced health assessment. Which finding is characteristic of this condition? a. Pink, frothy sputum b. Mild nasal congestion c. Transient grunting sounds d. Mild tachypnea upon exertion Answer: a. Pink, frothy sputum Rationale: Pink, frothy sputum is a classic sign of meconium aspiration syndrome, which occurs when the neonate inhales meconium-stained amniotic fluid. It requires immediate attention to prevent potential complications.
14. During an advanced health assessment, a nurse identifies a flat, purplish patch located on a neonate's lower back. Which intervention should the nurse prioritize? a. Initiate immediate phototherapy b. Apply a hydrocortisone cream c. Perform a blood glucose screening d. Evaluate for the presence of a sacral dimple Answer: d. Evaluate for the presence of a sacral dimple Rationale: A flat, purplish patch on a neonate's lower back

C:

Question: A neonate presents with cyanosis, tachypnea, and grunting. Which condition should the nurse suspect? A) Patent ductus arteriosus B) Transient tachypnea of the newborn C) Meconium aspiration syndrome D) Respiratory distress syndrome Answer: D) Respiratory distress syndrome Rationale: The symptoms of cyanosis, tachypnea, and grunting are indicative of respiratory distress syndrome, which results from inadequate surfactant production in premature neonates. Question: A newborn is noted to have a high-pitched cry, poor feeding, and hyperreflexia. Which condition should the nurse suspect? A) Neonatal abstinence syndrome B) Neonatal hypoglycemia C) Neonatal sepsis D) Neonatal tetanus Answer: A) Neonatal abstinence syndrome Rationale: The symptoms described are characteristic of neonatal abstinence syndrome, commonly seen in infants exposed to opioids in utero. Question: A neonate presents with jaundice within the first 24 hours of life. Which condition should the nurse suspect? A) Physiological jaundice

B) Breast milk jaundice C) Hemolytic disease of the newborn D) Biliary atresia Answer: C) Hemolytic disease of the newborn Rationale: Early onset jaundice is suggestive of hemolytic disease of the newborn, which occurs due to blood group incompatibility between the mother and the neonate. Question: When performing a neonatal assessment, which finding would be concerning for the nurse? A) Caput succedaneum B) Molding C) Fontanelle depression D) Bulging fontanelle Answer: D) Bulging fontanelle Rationale: A bulging fontanelle can indicate increased intracranial pressure, which requires immediate medical attention. Question: A newborn is diagnosed with congenital hypothyroidism. Which assessment finding is consistent with this condition? A) Hypotonia B) Hyperactivity C) Exophthalmos D) Tachypnea Answer: A) Hypotonia Rationale: Congenital hypothyroidism commonly presents with hypotonia due to decreased thyroid hormone

C) Erb's palsy D) Torticollis Answer: A) Brachial plexus injury Rationale: Asymmetric Moro reflex and limited movement of the arm are indicative of a brachial plexus injury, often resulting from birth trauma. Question: A newborn presents with excessive drooling, difficulty swallowing, and cyanosis. Which condition should the nurse suspect? A) Tracheoesophageal fistula B) Choanal atresia C) Cleft lip D) Esophageal atresia Answer: D) Esophageal atresia Rationale: The symptoms described are consistent with esophageal atresia, a condition where the upper esophagus ends in a blind pouch, leading to difficulty in swallowing and respiratory distress. Question: A newborn demonstrates a positive Barlow test and limited hip abduction. Which condition should the nurse suspect? A) Developmental dysplasia of the hip B) Legg-Calvé-Perthes disease C) Osteogenesis imperfecta D) Congenital hip dislocation Answer: A) Developmental dysplasia of the hip Rationale: A positive Barlow test and limited hip abduction are indicative of developmental dysplasia of the

hip, which requires further evaluation and management. Question: A neonate presents with a high-pitched, inspiratory noise and respiratory distress. Which condition should the nurse suspect? A) Laryngomalacia B) Tracheomalacia C) Choanal atresia D) Vocal cord paralysis Answer: A) Laryngomalacia Rationale: The described symptoms are consistent with laryngomalacia, a common cause of stridor in neonates due to floppy laryngeal structures. Question: A neonate is found to have a sacral dimple. What assessment should the nurse perform? A) Assessment for sacral edema B) Neurological assessment C) Assessment for spina bifida occulta D) Musculoskeletal assessment Answer: C) Assessment for spina bifida occulta Rationale: A sacral dimple may indicate the presence of spina bifida occulta, a congenital neural tube defect, necessitating further assessment for proper management. Question: A newborn exhibits poor weight gain, chronic diarrhea, and a distended abdomen. Which condition should the nurse suspect? A) Hirschsprung's disease B) Celiac disease

Cri-du-chat syndrome, a chromosomal disorder associated with intellectual disability and distinct physical features.