Asked by Rachel Cessna on May 31, 2024
Verified
A nurse performs an assessment on a healthy newborn. Which assessment finding will the nurse document as normal?
A) Cyanosis of the feet and hands for the first 48 hours
B) Triangle-shaped anterior fontanel
C) Sporadic motor movements
D) Weight of 4800 grams
Cyanosis
Bluish discoloration of the skin and mucous membranes caused by an excess of deoxygenated hemoglobin in the blood or a structural defect in the hemoglobin molecule.
Anterior Fontanel
The soft spot on the top of a baby's head where the skull bones have not yet joined.
Sporadic Motor Movements
Irregular, unpredictable physical movements that are not consistently repetitive.
- Recognize normal and abnormal developmental milestones and physical assessment findings in newborns and children.
Verified Answer
NL
Nataly LopezJun 06, 2024
Final Answer :
C
Explanation :
Movements in the newborn are generally sporadic, but they are symmetric and involve all four extremities. Cyanosis of the hands and feet is normal for the first 24 hours, not 48 hours. The diamond shape of the anterior fontanel and the triangular shape of the posterior fontanel are found between the unfused bones of the skull. The average newborn is 2700 to 4000 grams (6 to 9 pounds), not 4800 grams.
Learning Objectives
- Recognize normal and abnormal developmental milestones and physical assessment findings in newborns and children.
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