Health Promotion and Maintenance
45. A nurse performs a head-to-toe assessment on a newborn. Which finding should be of greatest concern to the nurse?
Health Promotion and Maintenance
45. A nurse performs a head-to-toe assessment on a newborn. Which finding should be of greatest concern to the nurse?
. Capillary refill time of 2 seconds.
. Transient mottling of the skin.
. Irregular respirations.
. Negative Babinski reflex.
Test-Taking Tip
The key word in the stem of the question is "newborn." Look for the assessment finding that is abnormal for a newborn.
Content Area: Child Health, Newborn; Integrated Process: Nursing Process, Assessment; Cognitive Level: Analysis; Client Need/Subneed: Health Promotion and Maintenance/Health Screening
Health Promotion and Maintenance
.
Answer 1 is incorrect because a capillary refill time of 2 seconds is a normal finding. Extended refill time would be a concern. Answer 2 is incorrect because transient mottling of the skin is likely caused by a decrease in environmental temperature or as a result of stress. Sustained mottling of the skin would be cause for concern. Answer 3 is incorrect because irregular, periodic breaths are normal findings in an infant. Apneic spells or respirations that never sustain any pattern would be a concern. Answer 4 is correct because the newborn should have a positive Babinski, or plantar, reflex. This reflex occurs when the toes extend in response to the stroking of the sole of the foot. A negative finding should occur in older infants and adults and is noted when the toes demonstrate a flexor response.