NURS 4403 Chapter 23: Nursing Care of the Newborn and Family
MULTIPLE CHOICE
1. An infant boy was born just a few minutes ago. The nurse is conduct
... [Show More] ing the initial assessment. Part of the assessment includes the Apgar score. The Apgar assessment is performed:
a. Only if the newborn is in obvious distress.
b. Once by the obstetrician, just after the birth.
c. At least twice, 1 minute and 5 minutes after birth.
d. Every 15 minutes during the newborn’s first hour after birth.
2. A new father wants to know what medication was put into his infant’s eyes and why it is needed. The nurse explains to the father that the purpose of the Ilotycin ophthalmic ointment is to:
a. Destroy an infectious exudate caused by Staphylococcus that could make the infant blind.
b. Prevent gonorrheal and chlamydial infection of the infant’s eyes potentially acquired from the birth canal.
c. Prevent potentially harmful exudate from invading the tear ducts of the infant’s eyes, leading to dry eyes.
d. Prevent the infant’s eyelids from sticking together and help the infant see.
3. The nurse is using the Ballard scale to determine the gestational age of a newborn. Which assessment finding is consistent with a gestational age of 40 weeks?
a. Flexed posture
b. Abundant lanugo
c. Smooth, pink skin with visible veins
d. Faint red marks on the soles of the feet
4. A 3.8-kg infant was delivered vaginally at 39 weeks after a 30-minute second stage. There was a nuchal cord. After birth the infant is noted to have petechiae over the face and upper back. Information given to the infant’s parents should be based on the knowledge that petechiae:
a. Are benign if they disappear within 48 hours of birth.
b. Result from increased blood volume.
c. Should always be further investigated.
d. Usually occur with forceps delivery.
5. A newborn is jaundiced and receiving phototherapy via ultraviolet bank lights. An appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy by this method would be to:
a. Apply an oil-based lotion to the newborn’s skin to prevent dying and cracking.
b. Limit the newborn’s intake of milk to prevent nausea, vomiting, and diarrhea.
c. Place eye shields over the newborn’s closed eyes.
d. Change the newborn’s position every 4 hours.
6. Early this morning, an infant boy was circumcised using the PlastiBell method. The nurse tells the mother that she and the infant can be discharged after:
a. The bleeding stops completely.
b. Yellow exudate forms over the glans.
c. The PlastiBell rim falls off.
d. The infant voids.
7. A mother expresses fear about changing her infant’s diaper after he is circumcised. What does the woman need to be taught to take care of the infant when she gets home?
a. Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours.
b. Apply constant, firm pressure by squeezing the penis with the fingers for at least 5 minutes if bleeding occurs.
c. Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change.
d. Wash off the yellow exudate that forms on the glans at least once every day to prevent infection.
8. When preparing to administer a hepatitis B vaccine to a newborn, the nurse should:
a. Obtain a syringe with a 25-gauge, 5/8-inch needle.
b. Confirm that the newborn’s mother has been infected with the hepatitis B virus.
c. Assess the dorsogluteal muscle as the preferred site for injection.
d. Confirm that the newborn is at least 24 hours old.
9. The nurse is performing a gestational age and physical assessment on the newborn. The infant appears to have an excessive amount of saliva. The nurse recognizes that this finding:
a. Is normal.
b. Indicates that the infant is hungry.
c. May indicate that the infant has a tracheoesophageal fistula or esophageal atresia.
d. May indicate that the infant has a diaphragmatic hernia.
10. As part of Standard Precautions, nurses wear gloves when handling the newborn. The chief reason is:
a. To protect the baby from infection.
b. That it is part of the Apgar protocol.
c. To protect the nurse from contamination by the newborn.
d. the nurse has primary responsibility for the baby during the first 2 hours.
11. The nurse’s initial action when caring for an infant with a slightly decreased temperature is to:
a. Notify the physician immediately.
b. Place a cap on the infant’s head and have the mother perform kangaroo care.
c. Tell the mother that the infant must be kept in the nursery and observed for the next 4 hours.
d. Change the formula because this is a sign of formula intolerance.
12. An Apgar score of 10 at 1 minute after birth would indicate a(n):
a. Infant having no difficulty adjusting to extrauterine life and needing no further testing.
b. Infant in severe distress who needs resuscitation.
c. Prediction of a future free of neurologic problems.
d. Infant having no difficulty adjusting to extrauterine life but who should be assessed again at 5 minutes after birth.
13. With regard to umbilical cord care, nurses should be aware that:
a. The stump can easily become infected.
b. A nurse noting bleeding from the vessels of the cord should immediately call for assistance.
c. The cord clamp is removed at cord separation.
d. The average cord separation time is 5 to 7 days.
14. In the classification of newborns by gestational age and birth weight, the appropriate for gestational age (AGA) weight would:
a. Fall between the 25th and 75th percentiles for the infant’s age.
b. Depend on the infant’s length and the size of the head.
c. Fall between the 10th and 90th percentiles for the infant’s age.
d. Be modified to consider intrauterine growth restriction (IUGR).
15. During the complete physical examination 24 hours after birth:
a. The parents are excused to reduce their normal anxiety.
b. The nurse can gauge the neonate’s maturity level by assessing the infant’s general appearance.
c. Once often neglected, blood pressure is now routinely checked.
d. When the nurse listens to the heart, the S1 and S2 sounds can be heard; the first sound is somewhat higher in pitch and sharper than the second.
16. As related to laboratory tests and diagnostic tests in the hospital after birth, nurses should be aware that:
a. All states test for phenylketonuria (PKU), hypothyroidism, cystic fibrosis, and sickle cell diseases.
b. Federal law prohibits newborn genetic testing without parental consent.
c. If genetic screening is done before the infant is 24 hours old, it should be repeated at age 1 to 2 weeks.
d. Hearing screening is now mandated by federal law.
17. Nurses can assist parents who are trying to decide whether their son should be circumcised by explaining:
a. The pros and cons of the procedure during the prenatal period.
b. That the American Academy of Pediatrics (AAP) recommends that all newborn boys be routinely circumcised.
c. That circumcision is rarely painful and any discomfort can be managed without medication.
d. That the infant will likely be alert and hungry shortly after the procedure.
18. As part of their teaching function at discharge, nurses should educate parents regarding safe sleep. Which statement is incorrect?
a. Prevent exposure to people with upper respiratory tract infections.
b. Keep the infant away from secondhand smoke.
c. Avoid loose bedding, water beds, and beanbag chairs.
d. Place the infant on his or her abdomen to sleep.
19. The normal term infant has little difficulty clearing the airway after birth. Most secretions are brought up to the oropharynx by the cough reflex. However, if the infant has excess secretions, the mouth and nasal passages can be cleared easily with a bulb syringe. When instructing parents on the correct use of this piece of equipment, it is important that the nurse teach them to:
a. Avoid suctioning the nares.
b. Insert the compressed bulb into the center of the mouth.
c. Suction the mouth first.
d. Remove the bulb syringe from the crib when finished.
20. When teaching parents about mandatory newborn screening, it is important for the nurse to explain that the main purpose is to:
a. Keep the state records updated.
b. Allow accurate statistical information.
c. Document the number of births.
d. Recognize and treat newborn disorders early.
21. To prevent the abduction of newborns from the hospital, the nurse should:
a. Instruct the mother not to give her infant to anyone except the one nurse assigned to
her that day.
b. Apply an electronic and identification bracelet to mother and infant.
c. Carry the infant when transporting him or her in the halls.
d. Restrict the amount of time infants are out of the nursery.
22. The nurse administers vitamin K to the newborn for which reason?
a. Most mothers have a diet deficient in vitamin K, which results in the infant’s being deficient.
b. Vitamin K prevents the synthesis of prothrombin in the liver and must be given by injection.
c. Bacteria that synthesize vitamin K are not present in the newborn’s intestinal tract.
d. The supply of vitamin K is inadequate for at least 3 to 4 months, and the newborn must be supplemented.
23. Nursing follow-up care often includes home visits for the new mother and her infant. Which information related to home visits is correct?
a. Ideally, the visit is scheduled within 72 hours after discharge.
b. Home visits are available in all areas.
c. Visits are completed within a 30-minute time frame.
d. Blood draws are not a part of the home visit.
MULTIPLE RESPONSE
24. Pain should be assessed regularly in all newborn infants. If the infant is displaying physiologic or behavioral cues indicating pain, measures should be taken to manage the pain. Examples of nonpharmacologic pain management techniques include (Select all that apply):
a. Swaddling.
b. Nonnutritive sucking.
c. Skin-to-skin contact with the mother.
d. Sucrose.
e. Acetaminophen.
25. Hearing loss is one of the genetic disorders included in the universal screening program. Auditory screening of all newborns within the first month of life is recommended by the American Academy of Pediatrics. Reasons for having this testing performed include (Select all that apply):
a. Prevention or reduction of developmental delay.
b. Reassurance for concerned new parents.
c. Early identification and treatment.
d. Helping the child communicate better.
e. Recommendation by the Joint Committee on Infant Hearing.
COMPLETION
26. At 1 minute after birth, the nurse assesses the infant and notes a heart rate of 80 beats/minute, some flexion of the extremities, a weak cry, grimacing, and a pink body with blue extremities. The nurse would calculate an Apgar score of: [Show Less]