Ch 23 - Nursing Care of the Newborn and Family
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.
d. Recognize and treat newborn disorders early.
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.
d. Recognize and treat newborn disorders early.
The mother of a circumcised infant reports to the nurse that while she is cleaning her child's penis, he cries out loudly. What question does the nurse ask the patient to understand the reason behind this? 1 "Are you applying A&D ointment while cleaning?" 2 "Are you cleaning the penis with lukewarm water?" 3 "Are you applying fresh petrolatum while cleaning?" 4 "Are you cleaning with prepackaged commercial wipes?"
"Are you cleaning with prepackaged commercial wipes?" Do not use prepackaged commercial baby wipes for cleaning the circumcised site because they can contain alcohol. Alcohol delays healing and also causes discomfort to the infant. The infant cries out loudly because of the discomfort. Washing the penis gently with lukewarm water is recommended to remove urine and feces. Fresh petrolatum is applied to reduce pain after each diaper change. The application of A&D ointment while cleaning is done to prevent the sticking of the penis to the discharge, as well as to increase the infant's comfort.
At 1 minute following birth, the newborn exhibited the following: heart rate of 155; loud, vigorous crying with active movement of all extremities; sneezing when nose is stimulated with a catheter; hands and feet bluish and cool to the touch. The Apgar score of this newborn should be recorded as________.
9 The newborn receives 2 points each for a heart rate over 100 beats/min, a vigorous cry, active movement, and sneezing as a response to nasal stimulation. The newborn receives 1 point for color since he exhibits acrocyanosis.
The nurse is taking care of a newborn. The nurse finds out that the infant weighs 1800 g and the mother's HBsAg status is unknown. When should the nurse administer the hepatitis B immune globulin (HGIB) vaccine to the infant? 1 9 hours after the infant is born 2 13 hours after the infant is born 3 14 hours after the infant is born 4 18 hours after the infant is born
9 hours after the infant is born If the mother's HBsAg status is unknown, then the infant's weight is considered to determine the time for the administration of the HBIG vaccine. The infant weighs 1800 g, so the HBIG vaccine is given within 12 hours after the infant's birth. Therefore the HBIG vaccine should be administered 9 hours after birth, not 13, 14, or 18 hours after. If the mother's HBsAg status is known and the baby weighs more than 2000 g, then the HBIG vaccine can be administered within a week of the newborn's birth. In such a situation, the vaccine can be administered at 13, 14, or 18 hours after the birth of the infant.
The nurse is assessing a neonate with hydrocephaly. What observation reported by the nurse would be consistent with the neonate's condition?
A head circumference greater than chest circumference Hydrocephaly is a condition where fluids accumulate around the neonate's brain. Hydrocephaly is confirmed when the neonate's head circumference is 4.5 cm greater than the chest circumference. If a neonate has a body weight of 7 pounds, it is the normal weight of a newborn and does not indicate any abnormalities. A neonatal heart rate with 120 beats/min indicates that the newborn is healthy. A head-to-heel length of 55 cm is the normal body length of any newborn. This factor does not lead to hydrocephaly.
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.
A, C, D, E
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
A. Are benign if they disappear within 48 hours of birth. Petechiae, or pinpoint hemorrhagic areas, acquired during birth may extend over the upper portion of the trunk and face. These lesions are benign if they disappear within 2 days of birth and no new lesions appear. Petechiae may result from decreased platelet formation. In this situation the presence of petechiae is most likely a soft-tissue injury resulting from the nuchal cord at birth. Unless they do not dissipate in 2 days, there is no reason to alarm the family. Petechiae usually occur with a breech presentation vaginal birth.
As part of their teaching function at discharge, nurses should tell parents that the baby's respiratory status should be protected by the following procedures: (Select all that apply.) A. Prevent exposure to people with upper respiratory tract infections B. Keep the infant away from secondhand smoke C. Avoid loose bedding, waterbeds, and beanbag chairs D. Do not let the infant sleep on his or her back E. Keep a bulb suction available at home.
A. Prevent exposure to people with upper respiratory tract infections B. Keep the infant away from secondhand smoke C. Avoid loose bedding, waterbeds, and beanbag chairs E. Keep a bulb suction available at home. Infants are vulnerable to respiratory infections; infected people must be kept away. Secondhand smoke can damage lungs. Infants can suffocate in loose bedding and furniture that can trap them. The infant should be laid down to sleep on his or her back for better breathing and to prevent sudden infant death syndrome. A bulb syringe will be useful if the baby needs suctioning of the mouth and nose at home to protect the airway.
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.
A. The stump can easily become infected. The cord stump is an excellent medium for bacterial growth. The nurse should first check the clamp (or tie) and apply a second one. If the bleeding does not stop, then the nurse calls for assistance. The cord clamp is removed after 24 hours when it is dry. The average cord separation time is 10 to 14 days.
Upon assessing the CRIES neonatal postoperative pain scale findings, the nurse concludes that the infant is experiencing severe pain. What finding made the nurse conclude this? Incorrect1 The infant wakes up frequently. 2 The infant's skin has a pink complexion. Correct3 The infant requires 40% oxygen support. 4 The infant's Heart rate was 110 beats/min.
According to the CRIES scale, the infant is experiencing severe pain when he or she requires more than 30% oxygen support to maintain normal functioning. The normal heart rate of an infant is 110 beats/min. The heart rate increases when the infant cries. A pink complexion is a normal indication, so a pink complexion does not cause the nurse to conclude that the infant is in severe pain.
The student nurse is asked to distinguish cutaneous jaundice from normal skin color of a neonate. What will the student nurse do to differentiate them?
Apply pressure on the forehead with a finger
The nurse auscultates a neonate in resting position and hears a murmur. What further assessments should the nurse make to know if the infant has any cardiac defects?
Assess BP in all 4 extremities When murmurs are heard, the nurse should check the neonates' BP from all four extremities to rule out congenital heart diseases. Circumference of the head is measured to detect head-related complications, such as microcephaly and hydrocephaly. However, it is unrelated to congenital heart disease. Assessing the body movements would correlate more with the muscular activity of the neonate but not with cardiac activity.
The nurse must administer erythromycin ophthalmic ointment to a newborn after birth. The nurse should: A. Instill within 15 minutes of birth for maximum effectiveness. B. Cleanse eyes from inner to outer canthus before administration. C. Apply directly over the cornea. D. Flush eyes 10 minutes after instillation to reduce irritation.
B. Cleanse eyes from inner to outer canthus before administration. Instillation of the ointment can be delayed for up to 1 hour to facilitate eye-to-eye contact between the newborn and parents, an activity that fosters bonding and attachment, especially for fathers. The newborn's eyes should be cleansed from the inner to the outer canthus before the administration of erythromycin ointment. Erythromycin should be applied into the conjunctival sac to avoid accidental injury to the eye. The eyes should not be flushed after instillation of the erythromycin.
Which of these statements are helpful and accurate nursing advice concerning bathing the new baby. (Select all that apply.) A. Newborns should be bathed every day, for the bonding as well as the cleaning B. Tub baths may be given before the infant's umbilical cord falls off and the umbilicus is healed. C. Only plain warm water can be used to preserve the skin's acid mantle. D. Powders are not recommended because the infant can inhale powder. E. Bathe immediately after feeding while baby is calm and relaxed.
B. Tub baths may be given before the infant's umbilical cord falls off and the umbilicus is healed. D. Powders are not recommended because the infant can inhale powder. Newborns do not need a bath every day, even if the parents enjoy it. The diaper area and creases under the arms and neck need more attention. Tub baths may be given as soon as an infant's temperature has stabilized. Unscented mild soap is appropriate to use to wash the infant. Powder is not recommended due to the risk of inhalation. Should a parent elect to use baby powder, it should never be sprinkled directly onto the baby's skin. The parent can apply a small amount of powder to his or her own hand and then apply to the infant. Do not bathe immediately after a feeding period because the increased handling may cause regurgitation.
The primary health care provider (PHP) prescribes ventilator support for a newborn. What finding would the PHP have assessed in the newborn?
Bluish discoloration of the skin
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.
C. Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change. With each diaper change, the penis should be washed off with warm water to remove any urine or feces. If bleeding occurs, the nurse should apply gentle pressure to the site of the bleeding with a sterile gauze square. This action is appropriate when caring for an infant who has had a circumcision. Yellow exudate covers the glans penis in 24 hours after the circumcision. This is part of normal healing and not an infective process. The exudate should not be removed.
Newborns are at high risk for injury if appropriate safety precautions are not implemented. Parents should be taught to: A. Place the newborn on the abdomen (prone) after feeding and for sleep. B. Avoid use of pacifiers. C. Use a rear-facing car seat. D. Use a crib with side rail slats that are no more than 3 inches apart.
C. Use a rear-facing car seat. The prone position is no longer recommended since it may interfere with chest expansion and lead to sudden infant death syndrome. Approved pacifiers are safe to use and fulfill a newborn's need to suck. If the newborn is breastfed, the use of pacifiers should be delayed until breastfeeding is well established to avoid the development of nipple confusion. Your baby should be in a rear-facing infant car safety seat from birth until age 2 years or until exceeding the car seat's limits for height and weight. Slats in a crib should be no more than 2 inches apart.
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?
Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change
The mother of a newborn reports that the baby scratches himself with his long nails. What would the nurse suggest to the mother? Select all that apply. 1 Clip the baby's nails every day. 2 Cut the nails while the baby is playing. 3 Cut the nails while the baby is sleeping. 4 Cut the nails while breastfeeding the baby. 5 Cover the baby's hands with loose-fitting mitts
Clip the baby's nails every day, Cut the nails while the baby is sleeping, Cover the baby's hands with loose-fitting mitts Cover the baby's hands with loose-fitting mitts. The nurse suggests that the mother cut the baby's nails when the baby is sleeping. Covering the hands of the baby with loose-fitting mitts would protect the baby from scratching himself. Since the nails do not grow very fast, it is not necessary to cut them daily. The infant's nails should not be cut while playing, because it may disturb the movement of extremities and could cause injuries to the fingers. Cutting the nails while the baby is breastfeeding is also not recommended, because it disturbs the feeding infant.
During assessment, the nurse finds that the heart rate of a neonate is 110 beats/min and respiratory rates vary from 35 to 40 breaths/min. The nurse also finds that the neonate has a pink complexion. What conclusion regarding the Apgar score would the nurse make from these findings? The neonate:
Exhibits normal findings
The nurse gives a newborn an Apgar score of 4. What condition observed in the neonate would be consistent with the score? 1 Clear eyes 2 Acrocyanosis 3 Flexed posture 4 Heart rate of 70 beats/min
Heart rate of 70 beats/min The Apgar score of 4 indicates that the neonate has difficulty adapting to the extrauterine environment. A heart rate of 70 beats/min is not a normal finding and can be consistent with the condition. Observations such as clear eyes, acrocyanosis, and flexed posture in the neonate are normal findings and suggest an Apgar score of 7 to 10. However, these findings are not consistent with the low Apgar score of 4.
The nurse is assessing a breastfed newborn 1 hour after birth. The nurse identified that the glucose levels are less than 25 mg/dL and immediately reported it to the primary health care provider (PHP). What medication administration does the nurse expect the PHP to advise?
IV dextrose infusion
After assessing an infant's health screening reports, the nurse instructs the mother to stop breastfeeding and switch to a soy-based formula. What findings most likely caused the nurse to recommend this change? 1 Elevated leucine levels in the infant 2 Increased galactose levels in the infant 3 Elevated methionine levels in the infant 4 Increased thyrotropin levels in the infant
Increased galactose levels in the infant Galactosemia is a condition where the galactose levels are elevated in an infant. If this condition is present, the nurse would instruct the mother to stop breastfeeding, because breast milk is contraindicated in infants with galactosemia. Elevated leucine causes maple syrup urine disease in an infant but is not a contraindication for breastfeeding. Elevated methionine causes homocystinuria in infants who are supplemented with thiamine. Elevated thyrotropin, or elevated thyroid-stimulating hormone (TSH), causes congenital hypothyroidism in infants. The parents of infants suffering from congenital hypothyroidism are instructed to get the newborn's bone mass tested regularly.
The nurse is assessing an infant with a body weight of 2500 g. Two days after delivery the blood report of the infant's mother confirms the presence of hepatitis B. What medication does the primary health care provider instruct the nurse to administer to the infant? 1 Intravenous (I.V.) hepatitis B vaccine 2 Intramuscular (IM) hepatitis B vaccine 3 Intravenous (I.V.) hepatitis B immune globulin (HBIG) 4 Intramuscular (IM) hepatitis B immune globulin (HBIG)
Intramuscular (IM) hepatitis B immune globulin (HBIG) A dose of IM HBIG should be given to the infant whose mother's hepatitis B surface antigen's (HBsAg) status is determined to be positive. The vaccine is also given to infants who weigh 2000 g or more before 1 week of age. The hepatitis B vaccine and HBIG are not given through the IV route in infants because of their adverse effects. The IM hepatitis B vaccine is given to infants born to hepatitis B surface antigen (HBsAg)-negative mothers before being discharged from the hospital.
The nurse observes increased bilirubin levels in the laboratory reports of a newborn. Which complication does the nurse expect in the newborn if this condition is poorly monitored? Syndactyly 2 Kernicterus 3 Rectal fistula 4 Down syndrome
Kernicterus Very high levels of bilirubin cause kernicterus. Bilirubin is a yellow pigment that is produced in the body during the normal recycling of old red blood cells (RBCs). High levels of bilirubin in the body can cause the skin to look yellow, a condition known as jaundice. Syndactyly is a condition where two or more digits are fused together. It is not associated with increased bilirubin levels. Rectal fistula is caused by the absence of the anal opening in the newborn. Down syndrome is a chromosome defect and is not associated with increased bilirubin levels.
The nurse is assessing a preterm baby and observes dark red skin color with harlequin signs on the skin. What does the nurse infer from these findings? The baby has: Hypotension. 2 Polycythemia. 3 Hyperthermia. 4 A neurologic disorder
Polycythemia - Polycythemia is common in preterm infants because of the presence of fetal red blood cells (RBCs) The dark red color skin of the newborn with harlequin signs indicates polycythemia. Polycythemia is common in preterm infants because of the presence of fetal red blood cells (RBCs). The presence of hypotension in the infant is indicated by gray coloration of the skin. The presence of hyperthermia in a newborn is indicated by blue coloration (cyanosis) of the skin. Neurologic disorders are associated with cyanosis but not with polycythemia
The nurse is educating the parents of a newborn about the use of the bulb syringe. Which statement from the parents indicates effective learning about the bulb syringe? "It is used in the baby to:
Prevent suffocation and clear airway obstruction The bulb syringe is used to prevent suffocation and clear airway obstruction of newborns, and hence, it prevents aspiration. If the newborn's anal opening prevents defecation, it leads to severe gastrointestinal abnormalities. The bulb syringe is not used to reduce the newborn's temperature during hypothermia. It is also not used to avoid heat loss from the newborn due to evaporation and convection. Heat loss from the newborn is avoided by using warm water for bathing, drying the newborn carefully, and avoiding exposing the newborn to drafts.
The nurse is assessing a neonate who was born on the way to hospital. Which nursing intervention should be performed to prevent apneic spells in the neonate? 1 Provide warmth to the neonate. 2 Provide ventilator support to the neonate. 3 Provide chest compressions to the neonate. 4 Clean the neonate's body with lukewarm water
Provide warmth to the neonate. The neonate born on the way to hospital may become hypothermic, so the nurse should gradually warm the neonate's body to avoid apneic spells (insufficiency breathing). Rapid warming may cause apneic spells. Thus the warming process should be gradual. Ventilator or chest compressions are given when a neonate already has respiratory distress, which is identified by assessing the heart rate. The nurse can use lukewarm water to clear the stains on the neonate's body only after thermal stability is achieved.
The nurse evaluates the blood pressure (BP) of a neonate and suspects a cardiac defect. What recordings of the neonate's BP confirm a cardiac defect? 1 The BP in the lower extremities is 60/40 mm Hg and in the upper extremities is 70/50 mm Hg. Correct2 The BP in the lower extremities is 50/40 mm Hg and in the upper extremities is 80/70 mm Hg. Incorrect3 The BP in the lower extremities is 70/40 mm Hg and in the upper extremities is 60/40 mm Hg. 4 The BP in the lower extremities is 80/40 mm Hg and in the upper extremities is 70/60 mm Hg.
Systolic BP should be 60 to 80 mm Hg, and diastolic BP should be 40 to 50 mmHg. When the recordings are varied by 20 mm Hg in both the extremities, it implies that the neonate has a cardiac defect, such as coarctation of the aorta. If the BP of the lower extremities is 50/40 mm Hg and that of the upper extremities is 80/70 mm Hg, it indicates that the neonate has a cardiac defect, such as coarctation of the aorta. The same recordings on all the extremities signify that the neonate's heart functions properly. Variations of 10 mm Hg are still considered a normal finding in a neonate.
Baby-friendly hospitals mandate their infants be put to breast within the first _______ after birth. a) 1 hour b) 30 minutes c) 2 hours d) 4 hours
a) 1 hour
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
a. Flexed posture
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.
a. Ideally, the visit is scheduled within 72 hours after discharge.
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.
a. Ideally, the visit is scheduled within 72 hours after discharge.
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.
a. Obtain a syringe with a 25-gauge, 5/8-inch needle.
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.
a. Swaddling. b. Nonnutritive sucking. c. Skin-to-skin contact with the mother. d. Sucrose.
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.
a. The pros and cons of the procedure during the prenatal period.
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.
a. The pros and cons of the procedure during the prenatal period.
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.
a. The stump can easily become infected.
The nurse examines a woman 1 hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action is to: a) Place her on a bedpan to empty her bladder b) Massage her fundus c) Call the physician d) Administer methylergonovine (Methergine), 0.2mg IM, which has been ordered prn
b) Massage her fundus
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.
b. Apply an electronic and identification bracelet to mother and infant.
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.
b. Prevent gonorrheal and chlamydial infection of the infant's eyes potentially acquired from the birth canal.
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.
b. Prevent gonorrheal and chlamydial infection of the infant's eyes potentially acquired from the birth canal.
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.
b. The nurse can gauge the neonate's maturity level by assessing the infant's general appearance.
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.
b. The nurse can gauge the neonate's maturity level by assessing the infant's general appearance.
Excessive blood loss after childbirth can have several causes; however, the most common is: a) Vaginal or vulvar hematomas b) Unrepaired lacerations of the vagina or cervix c) Failure of the uterine muscle to contract firmly d) Retained placental fragments
c) Failure of the uterine muscle to contract firmly
An infant boy was born just a few minutes ago. The nurse is conducting 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.
c. At least twice, 1 minute and 5 minutes after birth.
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.
c. Bacteria that synthesize vitamin K are not present in the newborn's intestinal tract.
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.
c. Bacteria that synthesize vitamin K are not present in the newborn's intestinal tract.
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.
c. Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change.
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.
c. Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change.
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).
c. Fall between the 10th and 90th percentiles for the infant's age.
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).
c. Fall between the 10th and 90th percentiles for the infant's age.
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.
c. If genetic screening is done before the infant is 24 hours old, it should be repeated at age 1 to 2 weeks.
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.
c. If genetic screening is done before the infant is 24 hours old, it should be repeated at age 1 to 2 weeks.
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.
c. May indicate that the infant has a tracheoesophageal fistula or esophageal atresia.
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.
c. May indicate that the infant has a tracheoesophageal fistula or esophageal atresia.
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.
c. Place eye shields over the newborn's closed eyes.
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.
c. To protect the nurse from contamination by the newborn.
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.
c. To protect the nurse from contamination by the newborn.
On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurse's first action is to: a) Begin an IV infusion of Ringer's lactate solution b) Assess the woman's vital signs c) Call the woman's primary health care provider d) Message the woman's fundus
d) Message the woman's fundus
Which finding would be a source of concern if noted during the assessment of a woman who is 12 hours' postpartum? a) Postural hypotension b) Temperature of 38 C c) Bradycardia- pulse rate of 55 beats/min d) Pain in left calf with dorsiflexion of left foot
d) Pain in left calf with dorsiflexion of left foot
Perineal care is an important infection control measure. When evaluation a postpartum woman's perineal care technique, the nurse would recognize the need for further instruction if the woman: a) Uses soap and warm water to wash the vulva and perineum b) Washes from symphysis pubis back to the episiotomy c) Changes her perineal pad every 2 to 3 hours d) Uses the peribottle to rinse upward into her vagina
d) Uses the peribottle to rinse upward into her vagina
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.
d. Place the infant on his or her abdomen to sleep.
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.
d. Place the infant on his or her abdomen to sleep.
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.
d. The infant voids.
Following circumcision of a newborn, the nurse provides instructions to his or her parents regarding postcircumcision care. The nurse should tell the parents to: 1 apply topical anesthetics with each diaper change. 2 expect a yellowish exudate to cover the glans after the first 24 hours. 3 change the diaper every 2 hours and cleanse the site with soap and water or baby wipes. 4 apply constant pressure to the site if bleeding occurs and call the physician
expect a yellowish exudate to cover the glans after the first 24 hours Parents should be taught that a yellow exudate will develop over the glans and should not be removed. Topical anesthetics are applied before the circumcision. Infant-comforting techniques are generally sufficient following the procedure. The diaper is changed frequently, but the site is cleansed with warm water only because soap and baby wipes can cause pain/burning and irritation at the site. Intermittent pressure is applied if bleeding occurs.
When placing a newborn under a radiant heat warmer to stabilize the temperature after birth, the nurse should: 1 place the thermistor probe on the left side of the chest. 2 cover the probe with a nonreflective material. 3 recheck the temperature by periodically taking a rectal temperature. 4 prewarm the radiant heat warmer and place the undressed newborn under it.
prewarm the radiant heat warmer and place the undressed newborn under it. The radiant warmer should be prewarmed so the infant does not experience more cold stress. The thermistor probe should be placed on the upper abdomen away from the ribs. It should be covered with reflective material. Rectal temperatures should be avoided because rectal thermometers can perforate the intestine, and the temperature may remain normal until cold stress is advanced.
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.
A, B, C, D
The nurse administers concentrated oral sucrose through the suckling method to a neonate before performing the heelstick method. Why would the nurse do this?
As a source of comfort to the infant The heelstick method is used to collect blood to estimate various biologic and chemical materials. The nurse administers oral sucrose to a neonate before performing a painful procedure such as the heelstick method to comfort the neonate. It is not necessary to hydrate the neonate before performing the heelstick method. Hydration of a neonate is usually achieved by administering human milk or infant formula. The infant's glucose levels are maintained by infusing dextrose; it is not used to recognize reflexes in infant.
Following circumcision of a newborn, the nurse provides instructions to his or her parents regarding postcircumcision care. The nurse should tell the parents to: A. Apply topical anesthetics with each diaper change. B. Expect a yellowish exudate to cover the glans after the first 24 hours. C. Change the diaper every 2 hours and cleanse the site with soap and water or baby wipes. D. Apply constant pressure to the site if bleeding occurs and call the physician.
B. Expect a yellowish exudate to cover the glans after the first 24 hours. Topical anesthetics are applied before the circumcision. Infant-comforting techniques are generally sufficient following the procedure. Parents should be taught that a yellow exudate will develop over the glans and should not be removed. The diaper is changed frequently, but the site is cleansed with warm water only since soap and baby wipes can cause pain/burning and irritation at the site. Intermittent pressure is applied if bleeding occurs.
When placing a newborn under a radiant heat warmer to stabilize the temperature after birth, the nurse should: A. Place the thermistor probe on the left side of the chest. B. Cover the probe with a nonreflective material. C. Recheck the temperature by periodically taking a rectal temperature. D. Prewarm the radiant heat warmer and place the undressed newborn under it.
D. Prewarm the radiant heat warmer and place the undressed newborn under it. The thermistor probe should be placed on the upper abdomen away from the ribs. It should be covered with reflective material. Rectal temperatures should be avoided since rectal thermometers can perforate the intestine, and the temperature may remain normal until cold stress is advanced. The radiant warmer should be prewarmed so the infant does not experience more cold stress.
A patient with a history of gonorrheal infection has just delivered a baby. What immediate intervention should the nurse provide to the newborn to ensure safety? 1 Place the newborn in incubator. 2 Administer ophthalmic solution. 3 Perform a heelstick puncture test. 4 Provide ventilator support to the newborn.
The nurse should administer erythromycin ophthalmic solution to the newborn within 2 hours of birth to prevent ophthalmia neonatorum caused by gonorrheal infection. Incubation is preferred when a neonate has hypothermia in order to regulate the body temperature. Heelstick puncture is performed to detect abnormalities in blood levels only if the neonate has any infection. Ventilator support is provided if the neonate's heart rate is below 100 beats/min. However, the heart rate is not decreased due to gonorrheal infection.
Newborns are at high risk for injury if appropriate safety precautions are not implemented. Parents should be taught to:
Use a rear-facing carseat
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.
a. Are benign if they disappear within 48 hours of birth.
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
a. Flexed posture
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.
a. Obtain a syringe with a 25-gauge, 5/8-inch needle.
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.
a. Prevention or reduction of developmental delay. c. Early identification and treatment. d. Helping the child communicate better. e. Recommendation by the Joint Committee on Infant Hearing.
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.
a. The stump can easily become infected.
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.
b. Apply an electronic and identification bracelet to mother and infant.
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.
b. Place a cap on the infant's head and have the mother perform kangaroo care.
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.
b. Place a cap on the infant's head and have the mother perform kangaroo care.
An infant boy was born just a few minutes ago. The nurse is conducting 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.
c. At least twice, 1 minute and 5 minutes after birth.
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.
c. Place eye shields over the newborn's closed eyes.
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.
c. Suction the mouth first.
Two hours after giving birth a primiparous woman becomes anxious and complains of intense perineal pain with a strong urge to have a bowel movement. Her fundus is firm, at the umbilicus, and midline. Her lochia is moderate rubra with no clots. The nurse suspects: a) Bladder distention b) Uterine atony c) Constipation d) Hematoma formation
d) Hematoma formation
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.
d. Infant having no difficulty adjusting to extrauterine life but who should be assessed again at 5 minutes after birth.
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.
d. Infant having no difficulty adjusting to extrauterine life but who should be assessed again at 5 minutes after birth.
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.
d. The infant voids.