Chapter 24 Nursing Care of the Newborn and Family Lowdermilk
The nurse hands over a newborn to the mother after phototherapy. After some time the mother reports that the child has loose stools. What would account for the infant's loose stools? 1. Bilirubin-induced gastric motility. 2. Decreased body fluids in the body. 3. Administration of glucose water. 4. Administration of infant formula.
1. Bilirubin-induced gastric motility.
What should nurses be aware of with regard to umbilical cord care? 1. The stump can easily become infected. 2. A nurse noting bleeding from the vessels of the cord should immediately call for assistance. 3. The cord clamp is removed at cord separation. 4. The average cord separation time is 5 to 7 days.
1. The stump can easily become infected.
The nurse observes generalized petechiae while assessing the skin of a neonate. What further intervention would the primary health care provider most likely request from the nurse? 1. Wrap the neonate in a warm blanket. 2. Administer vitamin K intramuscularly. 3. Provide ventilator support to the neonate. 4. Clean the neonate skin with lukewarm water.
2. Administer vitamin K intramuscularly.
The nurse is assessing the vital signs of a neonate 12 hours after birth. Which method should the nurse use to check the infant's temperature? 1. Rectal route 2. Axillary route 3. Temporal artery 4. Tymphanic route
2. Axillary route
A nurse must administer erythromycin ophthalmic ointment to a newborn after birth. How should the nurse do this? 1. Instill within 15 minutes of birth for maximum effectiveness 2. Cleanse eyes from inner to outer canthus before administration if necessary 3. Apply directly over the cornea 4. Flush eyes 10 minutes after instillation to reduce irritation
2. Cleanse eyes from inner to outer canthus before administration if necessary
The nurse must administer erythromycin ophthalmic ointment to a newborn after birth. What should the nurse do? 1. Instill within 15 minutes of birth for maximum effectiveness. 2. Cleanse eyes from inner to outer canthus before administration. 3. Apply directly over the cornea. 4. Flush eyes 10 minutes after instillation to reduce irritation.
2. Cleanse eyes from inner to outer canthus before administration.
The nurse is caring for a newborn with a high bilirubin level. What intervention does the nurse perform while using a fiberoptic blanket and phototherapy light for the newborn? 1. Provide intermittent feedings of glucose water. 2. Cover the newborn's eyes with an opaque mask. 3. Place the fully unclothed newborn under the light. 4. Wrap the naked newborn with a fiberoptic blanket.
2. Cover the newborn's eyes with an opaque mask.
Following circumcision of a newborn, the nurse provides instructions to his parents regarding postcircumcision care. The nurse should tell the parents to do what? 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.
2. Expect a yellowish exudate to cover the glans after the first 24 hours.
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? 1. Syndactyly 2. Kernicterus 3. Rectal fistula 4. Down syndrome
2. Kernicterus
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 what? 1. Hypotension. 2. Polycythemia. 3. Hyperthermia. 4. A neurologic disorder.
2. 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? 1. "It is used in the baby to prevent defecation from the anal opening." 2. "It is used in the baby to reduce the temperature during hypothermia." 3. "It is used in the baby to prevent suffocation and clear airway obstruction." 4. "It is used in the baby to avoid heat loss due to evaporation and convection."
3. "It is used in the baby to prevent suffocation and clear airway obstruction."
The nurse is assessing a neonate during the first hour of birth. Which signs of birth trauma does the nurse relate to a breech presentation? 1. Marked bruising over the entire face 2. Ecchymotic skin over the entire head 3. Bruising and swelling over the genitalia 4. Linear mark across both sides of the face
3. Bruising and swelling over the genitalia
The nurse is teaching the parents of an infant about prevention and care of diaper rash. Which intervention is appropriate when caring for an infant with diaper rashes? 1. Clean the diaper area with alcohol-based baby wipes. 2. Apply baby powder on the buttocks after cleaning. 3. Change the diaper when the infant voids or stools. 4. Avoid use of soap when cleaning the diaper area.
3. Change the diaper when the infant voids or stools.
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? 1. Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours. 2. Apply constant, firm pressure by squeezing the penis with the fingers for at least 5 minutes if bleeding occurs. 3. Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change. 4. Wash off the yellow exudate that forms on the glans at least once every day to prevent infection.
3. Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change.
Vitamin K is given to the newborn to do what? 1. Reduce bilirubin levels 2. Increase the production of red blood cells 3. Enhance the ability of blood to clot 4. Stimulate the formation of surfactant
3. Enhance the ability of blood to clot
Which intervention should the nurse perform to determine the baseline measurements of a newborn's physical growth? 1. Place and hold the naked newborn on the scale to obtain weight. 2. Allow the caregiver to hold the infant while measuring its length. 3. Measure the circumference of the head just above the eyebrows. 4. Check for plantar reflex by placing a finger in the newborn's palm.
3. Measure the circumference of the head just above the eyebrows.
The primary healthcare provider instructs the nurse to give a hepatitis B (HepB) vaccine to a newborn. How should the nurse administer the vaccine? Select all that apply. 1. Through the deltoid muscle 2. Via the dorsogluteal muscle 3. Using the vastuslateralis muscle 4. By inserting the needle at a 60-degree angle 5. By inserting the needle at a 90-degree angle
3. Using the vastuslateralis muscle 5. By inserting the needle at a 90-degree angle
The nurse is assessing a neonate with hydrocephaly. What observation reported by the nurse would be consistent with the neonate's condition? 1. A body weight of 7 pounds 2. A heart rate 120 beats/minute 3. A head-to-heel length of 55 cm 4. A head circumference greater than chest circumference
4. A head circumference greater than chest circumference
An Apgar score of 10 at 1 minute after birth indicates what? 1. An infant having no difficulty adjusting to extrauterine life and needing no further testing 2. An infant in severe distress that needs resuscitation 3. A prediction of a future free of neurologic problems 4. An infant having no difficulty adjusting to extrauterine life but who should be assessed again at 5 minutes after birth
4. An infant having no difficulty adjusting to extrauterine life but who should be assessed again at 5 minutes after birth
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? 1. Evaluate the size of the nipples. 2. Measure the circumference of the head. 3. Observe the symmetry of lip movement. 4. Apply pressure on the forehead with a finger.
4. 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? 1. Measure the circumference of the head. 2. Assess movements of the lower extremities. 3. Monitor blood pressure (BP) in upper extremities. 4. Assess blood pressure (BP) in all four extremities.
4. Assess blood pressure (BP) in all four extremities.
The nurse is assessing a breast-fed newborn 1 hour after birth. The nurse identified that the glucose levels are less than 25 mg/dl and immediately reports it to the primary health care provider (PHP). What medication administration does the nurse expect the PHP to advise? 1. Cow's milk orally 2. Infant formula orally 3. Intravenous (IV) saline infusion 4. Intravenous (IV) dextrose infusion
4. Intravenous (IV) dextrose infusion
When placing a newborn under a radiant heat warmer to stabilize temperature after birth, what should the nurse do? 1. Place the thermistor probe on the left side of the chest 2. Cover the probe with a nonreflective material 3. Recheck temperature by periodically taking a rectal temperature 4. Perform all examinations and activities under the warmer
4. Perform all examinations and activities under the warmer
16. Which explanation will assist the parents in their decision on whether they should circumcise their son? a. The circumcision procedure has pros and cons during the prenatal period. b. American Academy of Pediatrics (AAP) recommends that all male newborns be routinely circumcised. c. Circumcision is rarely painful, and any discomfort can be managed without medication. d. The infant will likely be alert and hungry shortly after the procedure.
A (Parents need to make an informed choice regarding newborn circumcision, based on the most current evidence and recommendations. Health care providers and nurses who care for childbearing families should provide factual, unbiased information regarding circumcision and give parents opportunities to discuss the risks and benefits of the procedure. The AAP and other professional organizations note the benefits but stop short of recommending routine circumcision. Circumcision is painful and must be managed with environmental, nonpharmacologic, and pharmacologic measures. After the procedure, the infant may be fussy for several hours, or he may be sleepy and difficult to awaken for feeding.)
21. A 3.8-kg infant was vaginally delivered at 39 weeks of gestation after a 30-minute second stage. A nuchal cord occurred. After the birth, the infant is noted to have petechiae over the face and upper back. Based on the nurses knowledge, which information regarding petechiae should be shared with the parents? a. Petechiae (pinpoint hemorrhagic areas) are benign if they disappear within 48 hours of childbirth. b.These hemorrhagic areas may result from increased blood volume. c.Petechiae should always be further investigated. d. Petechiae usually occur with a forceps delivery.
A (Petechiae that are 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 infant, the presence of petechiae is more likely a soft-tissue injury resulting from the nuchal cord at birth. Unless the lesions do not dissipate in 2 days, no reason exists to alarm the family. Petechiae usually occur with a breech presentation vaginal birth.)
28. 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 (The home visit is ideally scheduled within 72 hours after discharge. This timing allows early assessment and intervention for problems with feedings, jaundice, newborn adaptation, and maternal-infant interaction. Because of geographic distances, home visits are not available in all locales. Visits are usually 60 to 90 minutes in length to allow enough time for assessment and teaching. When jaundice is found, the nurse can discuss the implications and check the transcutaneous bilirubin level or draw blood for testing.)
10. A mother is changing the diaper of her newborn son and notices that his scrotum appears large and swollen. The client is concerned. What is the best response from the nurse? a. A large scrotum and swelling indicate a hydrocele, which is a common finding in male newborns. b. I don't know, but I'm sure it is nothing. c. Your baby might have testicular cancer. d. Your babys urine is backing up into his scrotum.
A (Explaining what a hydrocele is and its characteristics is the most appropriate response by the nurse. The swelling usually decreases without intervention. Telling the mother that the condition is nothing important is inappropriate and does not address the mothers concern. Furthermore, if the nurse is unaware of any abnormal-appearing condition, then she should seek assistance from additional resources. Telling the mother that her newborn might have testicular cancer is inaccurate, inappropriate, and could cause the new mother undue worry. Urine will not back up into the scrotum if the infant has a hydrocele. Any nurse caring for the normal newborn should understand basic anatomy.)
5. The nurse is using the New 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 (Term infants typically have a flexed posture. Abundant lanugo; smooth, pink skin with visible veins; and faint red marks are usually observed on preterm infants.)
25. The nurse should be cognizant of which important statement regarding care of the umbilical cord? a. The stump can become easily infected. b. If bleeding occurs from the vessels of the cord, then the nurse 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 cord stump is an excellent medium for bacterial growth. The nurse should first check the clamp (or tie) and apply a second one. If bleeding occurs and does not stop, then the nurse should call for assistance. The cord clamp is removed after 24 hours when it is dry. The average cord separation time is 10 to 14 days.)
17. The most serious complication of an infant heelstick is necrotizing osteochondritis resulting from lancet penetration of the bone. What approach should the nurse take when performing the test to prevent this complication? a. Lancet should penetrate at the outer aspect of the heel. b. Lancet should penetrate the walking surface of the heel. c. Lancet should penetrate the ball of the foot. d. Lancet should penetrate the area just below the fifth toe.
A (The stick should be made at the outer aspect of the heel and should penetrate no deeper than 2.4 mm. Repeated trauma to the walking surface of the heel can cause fibrosis and scarring that can lead to problems with walking later in life. The ball of the foot and the area below the fifth toe are inappropriate sites for a heelstick.)
1. Pain should be regularly assessed in all newborns. If the infant is displaying physiologic or behavioral cues that indicate pain, then measures should be taken to manage the pain. Which interventions are examples of nonpharmacologic pain management techniques? (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 (Swaddling, nonnutritive sucking, skin-to-skin contact with the mother, and sucrose are all appropriate nonpharmacologic techniques used to manage pain in neonates. Acetaminophen is a pharmacologic method of treating pain.)
3. The Period of Purple Crying is a program developed to educate new parents about infant crying and the dangers of shaking a baby. Each letter in the acronym PURPLE represents a key concept of this program. Which concepts are accurate? (Select all that apply.) a. P: peak of crying and painful expression b. U: unexpected c. R: baby is resting at last d. L: extremely loud e. E: evening
A, B, E (P: peak of crying; U: unexpectedcomes and goes; R: resists soothing; P: painline face; L: longlasting up to 5 hours a day; and E: evening or late afternoon. Many hospitals now provide parents with an educational DVD and provide education before discharge.)
2. As recently as 2005, the AAP revised safe sleep practices to assist in the prevention of SIDS. The nurse should model these practices in the hospital and incorporate this information into the teaching plan for new parents. Which practices are ideal for role modeling? (Select all that apply.) a. Fully supine position for all sleep b. Side-sleeping position as an acceptable alternative c. Tummy time for play d. Infant sleep sacks or buntings e. Soft mattress
A, C, D (The back to sleep position is now recommended as the only position for every sleep period. To prevent positional plagiocephaly (flattening of the head) the infant should spend time on his or her abdomen while awake and for play. Loose sheets and blankets may be dangerous because they could easily cover the babys head. The parents should be instructed to tuck any bedding securely around the mattress or use sleep sacks or bunting bags instead. The side-sleeping position is no longer an acceptable alternative position, according to the AAP. Infants should always sleep on a firm surface, ideally a firm crib mattress covered by a sheet only. Quilts and sheepskins, among other bedding, should not be placed under the infant.)
4. 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 AAP. What is the rationale for having this testing performed? (Select all that apply.) a. Prevents or reduces developmental delays b. Reassures concerned new parents c. Provides early identification and treatment d. Helps the child communicate better e. Is recommended by the Joint Committee on Infant Hearing
A, C, D, E (New parents are often anxious regarding auditory screening and its impending results; however, parental anxiety is not the reason for performing the screening test. Auditory screening is usually performed before hospital discharge. Importantly, the nurse ensures the parents that the infant is receiving appropriate testing and fully explains the test to the parents. For infants who are referred for further testing and follow-up, providing further explanation and emotional support to the parents is an important responsibility for the nurse. All other responses are appropriate reasons for auditory screening of the newborn. Infants who do not pass the screening test should have it repeated. If the infant still does not pass the test, then he or she should have a full audiologic and medical evaluation by 3 months of age. If necessary, the infant should be enrolled in an early intervention program by 6 months of age.)
27. Which intervention by the nurse would reduce the risk of abduction of the newborn from the hospital? a. Instructing the mother not to give her infant to anyone except the one nurse assigned to her that day b. Applying an electronic and identification bracelet to the mother and the infant c. Carrying the infant when transporting him or her in the halls d. Restricting the amount of time infants are out of the nursery
B (A measure taken by many facilities is to band both the mother and the baby with matching identification bracelets and band the infant with an electronic device that will sound an alarm if the infant is removed from the maternity unit. It is impossible for one nurse to be on call for one mother and baby for the entire shift; therefore, parents need to be able to identify the nurses who are working on the unit. Infants should always be transported in their bassinette for both safety and security reasons. All maternity unit nursing staff should have unique identification bracelets in comparison with the rest of the hospital. Infants should remain with their parents and spend as little time in the nursery as possible.)
12. At 1 minute after birth a nurse assesses an infant and notes a heart rate of 80 beats per minute, some flexion of extremities, a weak cry, grimacing, and a pink body but blue extremities. Which Apgar score does the nurse calculate based upon these observations and signs? a. 4 b. 5 c. 6 d. 7
B (Each of the five signs the nurse notes scores a 1 on the Apgar scale, for a total of 5. A score of 4 is too low for this infant. A score of 6 is too high for this infant. A score of 7 is too high for an infant with this presentation.)
23. What is the nurses initial action while caring for an infant with a slightly decreased temperature? a. Immediately notify the physician. b. Place a cap on the infants 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; a decreased body temperature is a sign of formula intolerance.
B (Keeping the head well covered with a cap prevents further heat loss from the head, and placing the infant skin-to-skin against the mother should increase the infants temperature. Nursing actions are needed first to correct the problem. If the problem persists after the interventions, physician notification may then be necessary. A slightly decreased temperature can be treated in the mothers room, offering an excellent time for parent teaching on the prevention of cold stress. Mild temperature instability is an expected deviation from normal during the first days after childbirth as the infant adapts to external life.)
2. A new father wants to know what medication was put into his infants eyes and why it is needed. How does the nurse explain the purpose of the erythromycin (Ilotycin) ophthalmic ointment? a. Erythromycin (Ilotycin) ophthalmic ointment destroys an infectious exudate caused by Staphylococcus that could make the infant blind. b. This ophthalmic ointment prevents gonorrheal and chlamydial infection of the infants eyes, potentially acquired from the birth canal. c. Erythromycin (Ilotycin) prevents potentially harmful exudate from invading the tear ducts of the infants eyes, leading to dry eyes. d. This ointment prevents the infants eyelids from sticking together and helps the infant see.
B (The nurse should explain that prophylactic erythromycin ophthalmic ointment is instilled in the eyes of all neonates to prevent gonorrheal and chlamydial infection that potentially could have been acquired from the birth canal. This prophylactic ophthalmic ointment is not instilled to prevent dry eyes and has no bearing on vision other than to protect against infection that may lead to vision problems.)
14. The nurse is completing a physical examination of the newborn 24 hours after birth. Which component of the evaluation is correct? a. The parents are excused to reduce their normal anxiety. b. The nurse can gauge the neonates maturity level by assessing his or her general appearance. c. Once often neglected, blood pressure is now routinely checked. d. When the nurse listens to the neonates heart, the S1 and S2 sounds can be heard; the S1sound is somewhat higher in pitch and sharper than the S2 sound.
B (The nurse is looking at skin color, alertness, cry, head size, and other features. The parents presence actively involves them in child care and gives the nurse the chance to observe their interactions. Blood pressure is not usually taken unless cardiac problems are suspected. The S2 sound is higher and sharper than the S1 sound.)
15. The nurse is teaching new parents about metabolic screening for the newborn. Which statement is most helpful to these clients? 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 performed before the infant is 24 hours old, then it should be repeated at age 1 to 2 weeks. d. Hearing screening is now mandated by federal law.
C (If testing is performed before the infant is 24 hours old, then genetic screening should be repeated when the infant is 1 to 2 weeks old. All states test for PKU and hypothyroidism but not for other genetic defects. Federal law mandates newborn genetic screening; however, parents can decline the testing. A waiver should be signed, and a notation made in the infants medical record. Federal law does not mandate screening for hearing problems; however, the majority of states have enacted legislation mandating newborn hearing screening. In the United States, the majority (95%) of infants are screened for hearing loss before discharge from the hospital.)
18. If the newborn has excess secretions, the mouth and nasal passages can be easily cleared with a bulb syringe. How should the nurse instruct the parents on the use of this instrument? 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 (The mouth should always be suctioned first to prevent the infant from inhaling pharyngeal secretions by gasping as the nares are suctioned. After compressing the bulb, the syringe should be inserted into one side of the mouth. If it is inserted into the center of the mouth, then the gag reflex is likely to be initiated. When the infants cry no longer sounds as though it is through mucus or a bubble, suctioning can be stopped. The nasal passages should be suctioned one nostril at a time. The bulb syringe should remain in the crib so that it is easily accessible if needed again.)
4. What is the rationale for the administration of vitamin K to the healthy full-term newborn? a. Most mothers have a diet deficient in vitamin K, which results in the infant being deficient. b. Vitamin K prevents the synthesis of prothrombin in the liver and must be administered by injection. c. Bacteria that synthesize vitamin K are not present in the newborns intestinal tract. d. The supply of vitamin K in the healthy full-term newborn is inadequate for at least 3 to 4 months and must be supplemented.
C (Vitamin K is provided because the newborn does not have the intestinal flora to produce this vitamin for the first week. The maternal diet has no bearing on the amount of vitamin K found in the newborn. Vitamin K promotes the formation of clotting factors in the liver and is used for the prevention and treatment of hemorrhagic disease in the newborn. Vitamin K is not produced in the intestinal tract of the newborn until after microorganisms are introduced. By day 8, normal newborns are able to produce their own vitamin K.)
9. The nurse is performing a gestational age and physical assessment on the newborn. The infant appears to have an excessive amount of saliva. This clinical finding may be indicative of what? a. Excessive saliva is a normal finding in the newborn. b. Excessive saliva in a neonate indicates that the infant is hungry. c. It may indicate that the infant has a tracheoesophageal fistula or esophageal atresia. d. Excessive saliva may indicate that the infant has a diaphragmatic hernia.
C (The presence of excessive saliva in a neonate should alert the nurse to the possibility of a tracheoesophageal fistula or esophageal atresia. Excessive salivation may not be a normal finding and should be further assessed for the possibility that the infant has an esophageal abnormality. The hungry infant reacts by making sucking motions, rooting, or making hand-to-mouth movements. The infant with a diaphragmatic hernia exhibits severe respiratory distress.)
3. A nurse is assessing a newborn girl who is 2 hours old. Which finding warrants a call to the health care provider? a. Blood glucose of 45 mg/dl using a Dextrostix screening method b. Heart rate of 160 beats per minute after vigorously crying c. Laceration of the cheek d. Passage of a dark black-green substance from the rectum
C (Accidental lacerations can be inflicted by a scalpel during a cesarean birth. They are most often found on the scalp or buttocks and may require an adhesive strip for closure. Parents would be overly concerned about a laceration on the cheek. A blood glucose level of 45 mg/dl and a heart rate of 160 beats per minute after crying are both normal findings that do not warrant a call to the physician. The passage of meconium from the rectum is an expected finding in the newborn.)
13. Which statement accurately describes an appropriate-for-gestational age (AGA) weight assessment? a. AGA weight assessment falls between the 25th and 75th percentiles for the infants age. b. AGA weight assessment depends on the infants length and the size of the newborns head. c. AGA weight assessment falls between the 10th and 90th percentiles for the infants age. d. AGA weight assessment is modified to consider intrauterine growth restriction (IUGR).
C (An AGA weight falls between the 10th and 90th percentiles for the infants age. The AGA range is larger than the 25th and 75th percentiles. The infants length and head size are measured, but these measurements do not affect the normal weight designation. IUGR applies to the fetus, not to the newborns weight.)
1. An infant boy was delivered minutes ago. The nurse is conducting the initial assessment. Part of the assessment includes the Apgar score. When should the Apgar assessment be 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 newborns first hour after birth
C (Apgar scoring is performed at 1 minute and at 5 minutes after birth. Scoring may continue at 5-minute intervals if the infant is in distress and requires resuscitation efforts. The Apgar score is performed on all newborns. Apgar score can be completed by the nurse or the birth attendant. The Apgar score permits a rapid assessment of the newborns transition to extrauterine life. An interval of every 15 minutes is too long to wait to complete this assessment.)
22. A mother expresses fear about changing her infants diaper after he is circumcised. What does the client need to be taught to care for her newborn son? 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.Gently cleanse the penis with water and apply 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 (Gently cleansing the penis with water and applying petroleum jelly around the glans after each diaper change are appropriate techniques when caring for an infant who has had a circumcision. With each diaper change, the penis should be washed with warm water to remove any urine or feces. If bleeding occurs, then the mother should apply gentle pressure to the site of the bleeding with a sterile gauze square. Yellow exudates are part of normal healing and cover the glans penis 24 hours after the circumcision; yellow exudates are not an infective process and should not be removed.)
11. What is the primary rationale for nurses wearing gloves when handling the newborn? a. To protect the baby from infection b. As part of the Apgar protocol c. To protect the nurse from contamination by the newborn d. Because the nurse has the primary responsibility for the baby during the first 2 hours
C (With the possibility of transmission of viruses such as HBV and the human immunodeficiency virus (HIV) through maternal blood and amniotic fluid, the newborn must be considered a potential contamination source until proven otherwise. As part of Standard Precautions, nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing. Proper hand hygiene is all that is necessary to protect the infant from infection. Wearing gloves is not necessary to complete the Apgar score assessment. The nurse assigned to the mother-baby couplet has primary responsibility for the newborn, regardless of whether or not she wears gloves.)
6. A newborn is jaundiced and is receiving phototherapy via ultraviolet bank lights. What is the most appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy? a. Applying an oil-based lotion to the newborns skin to prevent dying and cracking b. Limiting the newborns intake of milk to prevent nausea, vomiting, and diarrhea c. Placing eye shields over the newborns closed eyes d. Changing the newborns position every 4 hours
C (The infants eyes must be protected by an opaque mask to prevent overexposure to the light. Eye shields should completely cover the eyes but not occlude the nares. Lotions and ointments should not be applied to the infant because they absorb heat and can cause burns. The lights increase insensible water loss, placing the infant at risk for fluid loss and dehydration. Therefore, adequate hydration is important for the infant. The infant should be turned every 2 hours to expose all body surfaces to the light.)
19. As part of the infant discharge instructions, the nurse is reviewing the use of the infant car safety seat. Which information is the highest priority for the nurse to share? a. Infant carriers are okay to use until an infant car safety seat can be purchased. b. For traveling on airplanes, buses, and trains, infant carriers are satisfactory. c. Infant car safety seats are used for infants only from birth to 15 pounds. d. Infant car seats should be rear facing and placed in the back seat of the car.
D (An infant placed in the front seat could be severely injured by an air bag that deploys during an automobile accident. Infants should travel only in federally approved, rear-facing safety seats secured in the rear seat and only in federally approved safety seats even when traveling on a commercial vehicle. Infants should use a rear-facing car seat from birth to 20 pounds and to age 1 year.)
24. How should the nurse interpret an Apgar score of 10 at 1 minute after birth? a. The infant is having no difficulty adjusting to extrauterine life and needs no further testing. b. The infant is in severe distress and needs resuscitation. c. The nurse predicts a future free of neurologic problems. d. The infant is having no difficulty adjusting to extrauterine life but should be assessed again at 5 minutes after birth.
D (An initial Apgar score of 10 is a good sign of healthy adaptation; however, the test must be repeated at the 5-minute mark.)
29. Screening for critical congenital heart disease (CCHD) was added to the uniform screening panel in 2011. The nurse has explained this testing to the new mother. Which action by the nurse related to this test is correct? a. Screening is performed when the infant is 12 hours of age. b. Testing is performed with an electrocardiogram. c. Oxygen (O2) is measured in both hands and in the right foot. d. A passing result is an O2 saturation of 95%.
D (Screening is performed when the infant is between 24 and 48 hours of age. The test is performed using pulse oximetry technology. O2 is measured in the right hand and one foot. A passing result is an O2 saturation of 95% with a 3% absolute difference between upper and lower extremity readings.)
26. As part of their teaching function at discharge, nurses should educate parents regarding safe sleep. Based on the most recent evidence, which information is incorrect and should be discussed with parents? 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 (The infant should be laid down to sleep on his or her back for better breathing and to prevent sudden infant death syndrome (SIDS). Grandmothers may encourage the new parents to place the infant on the abdomen; however, evidence shows back to sleep reduces SIDS. Infants are vulnerable to respiratory infections; therefore, infected people must be kept away. Secondhand smoke can damage lungs. Infants can suffocate in loose bedding and in furniture that can trap them. Per AAP guidelines, infants should always be placed back to sleep and allowed tummy time to play to prevent plagiocephaly.)
20. A nurse is responsible for teaching new parents regarding the hygienic care of their newborn. Which instruction should the nurse provide regarding bathing? a. Avoid washing the head for at least 1 week to prevent heat loss. b. Sponge bathe the newborn for the first month of life. c. Cleanse the ears and nose with cotton-tipped swabs, such as Q-tips. d. Create a draft-free environment of at least 24 C (75 F) when bathing the infant.
D (The temperature of the room should be 24 C (75 F), and the bathing area should be free of drafts. To prevent heat loss, the infants head should be bathed before unwrapping and undressing. Tub baths may be initiated from birth. Ensure that the infant is fully immersed. Q-tips should not be used; they may cause injury. A corner of a moistened washcloth should be twisted into shape so that it can be used to cleanse the ears and nose.)