Newborn Assessment > Maternal & Newborn
Exam Review
Eyes, Ears, and Oral Cavity
Total Questions : 5
Showing 5 questions, Sign in for moreA nurse is assessing a newborn’s eyes.
The nurse should identify that which of the following is an expected finding?
Explanation
The newborn has a red reflex in both eyes.This is an expected finding that indicates the absence of cataracts or other eye abnormalities.The red reflex test is performed by using an ophthalmoscope to shine a light into the baby’s eyes and observing the reflection.
The newborn has blue or gray eyes at birth: This statement is wrong because eye color can vary at birth and may change over time.Eye color is determined by the amount and distribution of melanin in the iris.
The newborn has a nystagmus when looking to the side.This statement is wrong because nystagmus is an abnormal eye movement that can indicate a neurological problem or a visual impairment.
The newborn has a strabismus when focusing on an object.This statement is wrong because strabismus is a misalignment of the eyes that can cause amblyopia (lazy eye) or double vision.Strabismus may be present at birth or develop later in life.
A nurse is examining a newborn’s ears.
The nurse should identify that which of the following findings may indicate a chromosomal disorder?
Explanation
The newborn has low-set ears.
Low-set ears are ears that are positioned below the normal horizontal line drawn across both inner canthi of the eyes.Low-set ears may indicate a chromosomal disorder, such asDiGeorge syndromeorNoonan syndrome, or other congenital anomalies.
Choice B is wrong because small ear canals are not a sign of a chromosomal disorder, but rather a variation of normal anatomy.
Choice C is wrong because dry cerumen in the ears is not a sign of a chromosomal disorder, but rather a result of dehydration or lack of humidity.
Choice D is wrong because prominent antihelices are not a sign of a chromosomal disorder, but rather a normal feature of the external ear.
The antihelix is the curved prominence of cartilage parallel with and inside the helix (the rim) of the ear.
A nurse is inspecting a newborn’s oral cavity.
The nurse should identify that which of the following findings is a normal variation?
Explanation
Epstein’s pearls on the gums or palate are small, white cysts that are common and harmless in newborns.
They usually disappear within a few weeks without treatment.
Choice B is wrong because thrush on the tongue or gums is a fungal infection that causes white patches and soreness in the oral cavity.
It is not a normal variation and may require antifungal medication.
Choice C is wrong because petechiae on the hard palate are tiny red spots that indicate bleeding under the skin.
They are not a normal variation and may be caused by trauma, infection, or clotting disorders.
Choice D is wrong because yellowing of the hard palate is a sign of jaundice, which is a condition where the skin and mucous membranes turn yellow due to high levels of bilirubin in the blood.
It is not a normal variation and may indicate liver problems or hemolytic disease.
Normal ranges for oral cavity findings in newborns are:
• Gums: pink and moist, no inflammation or bleeding
• Teeth: none or natal teeth (present at birth), which may need to be removed if loose or interfering with feeding
• Tongue: pink and moist, no lesions or coating
A nurse is caring for a newborn who has thrush, an oral fungal infection.
Which of the following medications should the nurse expect to administer to treat this condition?
Explanation
Nystatin.Nystatin is an antifungal medicine that can be given as drops to treat oral thrush, a fungal infection in the mouth, in newborns.
Some possible explanations for the other choices are:
Acyclovir is an antiviral medicine that is used to treat infections caused by herpes viruses, such as cold sores or genital herpes.
It is not effective against fungal infections like thrush.
•Amoxicillin is an antibiotic medicine that is used to treat bacterial infections, such as ear infections or pneumonia.
It can actually increase the risk of developing thrush by killing the normal bacteria in the mouth that help prevent fungal overgrowth.
• Fluconazole is another antifungal medicine that can be used to treat thrush in some cases, especially in immunocompromised infants or when nystatin is not effective.
A nurse is teaching a new mother about how to care for her newborn’s eyes, ears, and oral cavity.
Which of the following instructions should the nurse include? (Select all that apply).
Explanation
The correct answer is choice A, D, and E.The nurse should instruct the mother to clean the newborn’s eyes with warm water and cotton balls from the inner to the outer canthus to prevent infection and remove any discharge.The nurse should also advise the mother to avoid using cotton-tipped applicators to clean the newborn’s ears because they can damage the eardrum or push cerumen deeper into the ear canal.Additionally, the nurse should tell the mother to report any signs of eye infection, such as redness, swelling, or discharge, to the provider as soon as possible.
Choice B is wrong because using a bulb syringe to suction any drainage from the newborn’s ears can cause trauma or infection
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