The nurse is working with a student nurse during assessment of a 2-hour-old newborn. Which action indicates that the student nurse understands neonatal assessment? The student nurse:
1. Listens to bowel sounds then assesses the head for skull consistency, and size and tension of fontanels.
2. Checks for Ortolani's sign, then palpates femoral pulse, then assesses respiratory rate.
3. Determines skin color, then describes shape of the chest and looks at structures and flexion of the feet.
4. Counts the number of cord vessels, then assess genitals, then sclera color and eyelids.
3
Rationale:
1. The assessment should proceed in a head-to-toe order; the head should be assessed before the bowel sounds.
2. The assessment should proceed in a head-to-toe order; the respiratory rate should be assessed first, when the infant is at rest and undisturbed.
3. This assessment proceeds in a head-to-toe fashion.
4. The assessment should proceed in a head-to-toe order; the sclera and eye assessment should be done prior to assessing genitals.
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