Practice Question
The nurse is assessing a full-term newborn during routine care in the postpartum unit. Which of the following assessment findings require the nurse notify the healthcare provider? (Select all that apply)
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Correct Answer:
Seizure activity
Rationale:
🟦 Seizure activity in a full-term newborn is never normal and indicates acute neurologic dysfunction that may be related to hypoglycemia, hypoxia, infection, or intracranial pathology.
🟦 Hypotonia reflects abnormal muscle tone, suggesting possible central nervous system injury, metabolic disturbance, or sepsis.
🟦 Absence of the Moro reflex in a term newborn is abnormal and may indicate neurologic impairment, brachial plexus injury, or CNS damage.
🟦 Jitteriness that does not resolve with feeding suggests causes beyond transient hypoglycemia, such as electrolyte imbalance, drug withdrawal, or neurologic pathology.
🟦 A high-pitched, shrill cry is a classic warning sign of neurologic irritation or increased intracranial pressure, requiring immediate provider notification.
Positive Babinski reflex
🟦 A positive Babinski reflex is expected in newborns due to immature neurologic pathways.
🟦 It normally disappears as the nervous system matures.
Mild tremors that stop when the newborn is comforted
🟦 Tremors that resolve with comfort are benign and common in healthy newborns.
🟦 They are associated with immature neuromuscular control, not pathology.
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This question is from Exam 5 - Module 9 which contains 72 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: General Exams
- Domain: 🤱🏼Maternity & Newborn Care
- Answer Choices: 7