RNC-NIC Neonatal Assessment 3

Question 1

A term neonate has an Apgar score of 4 at 5 minutes. Which combination of findings accounts for this score?

Accepted Answer

HR <100, weak cry, some flexion, grimace, pink body/blue extremities

Answer

An Apgar of 4 at 5 minutes with HR <100 (1), weak cry (1), some flexion (1), grimace (1), and acrocyanosis (0) totals 4, indicating moderate depression requiring intervention.

Question 2

During assessment of a 30-week preterm neonate, the nurse notes the absence of the cremasteric reflex in a male infant. This finding is:

Accepted Answer

Normal for gestational age as the reflex develops near term

Answer

The cremasteric reflex is absent in preterm neonates and develops closer to term gestation, making its absence a normal finding at 30 weeks.

Question 3

A neonate at 26 weeks gestation has a lanugo distribution limited to the shoulders and upper back. Using the New Ballard Score, this physical maturity criterion scores:

Accepted Answer

3

Answer

On the New Ballard Score, lanugo thinning with sparse areas on the back scores 3, as lanugo disappears progressively from the face and trunk toward the back with increasing maturity.

Question 4

When assessing muscle tone in a term neonate, the nurse places the infant in ventral suspension. Which finding indicates normal tone?

Accepted Answer

The infant maintains the head at 45 degrees below horizontal with some limb flexion

Answer

In ventral suspension, a term neonate with normal tone maintains the head at approximately 45 degrees below horizontal with partial limb flexion, demonstrating appropriate axial and appendicular tone.

Question 5

A neonate is noted to have a positive Ortolani maneuver during hip assessment. The nurse understands this finding indicates:

Accepted Answer

A dislocated hip being reduced back into the acetabulum

Answer

A positive Ortolani sign (a palpable 'clunk' with abduction) indicates a dislocated femoral head relocating into the acetabulum, diagnostic of developmental dysplasia of the hip.

(RNC-NIC) Registered Nurse Certified in Neonatal Intensive Care Practice Test

(RNC-NIC) Registered Nurse Certified in Neonatal Intensive Care Practice Test

RNC-NIC Neonatal Assessment 3