Deck 24: Nursing Care of the Newborn and Family

Question 1

Early this morning,an infant boy was circumcised using the PlastiBell method.Based on the nurse's evaluation,when will the infant be ready for discharge?

A) When the bleeding completely stops
B) When yellow exudate forms over the glans
C) When the PlastiBell plastic rim (bell) falls off
D) When the infant voids

Answer 1

When the infant voids

Question 2

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

Answer 2

To protect the nurse from contamination by the newborn

Question 3

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.

Answer 3

Create a draft-free environment of at least 24° C (75° F) when bathing the infant.

Question 4

A new father wants to know what medication was put into his infant's 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 infant's eyes, potentially acquired from the birth canal.
C) Erythromycin (Ilotycin) prevents potentially harmful exudate from invading the tear ducts of the infant's eyes, leading to dry eyes.
D) This ointment prevents the infant's eyelids from sticking together and helps the infant see.

Question 5

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 baby's urine is backing up into his scrotum."

Question 6

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.

Question 7

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.

Question 8

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

Question 9

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.

Question 10

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.

Question 11

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 neonate's 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 neonate's heart, the S₁ and S₂ sounds can be heard; the S₁ sound is somewhat higher in pitch and sharper than the S₂ sound.

Question 12

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 newborn's skin to prevent dying and cracking
B) Limiting the newborn's intake of milk to prevent nausea, vomiting, and diarrhea
C) Placing eye shields over the newborn's closed eyes
D) Changing the newborn's position every 4 hours

Question 13

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.

Question 14

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

Question 15

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

Question 16

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 newborn's 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.

Question 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.

Question 18

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 newborn's first hour after birth

Question 19

The nurse is preparing to administer a hepatitis B virus (HBV)vaccine to a newborn.Which intervention by the nurse is correct?

A) Obtaining a syringe with a 25-gauge, 5/8-inch needle for medication administration
B) Confirming that the newborn's mother has been infected with the HBV
C) Assessing the dorsogluteal muscle as the preferred site for injection
D) Confirming that the newborn is at least 24 hours old

Question 20

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 infant's age.
B) AGA weight assessment depends on the infant's length and the size of the newborn's head.
C) AGA weight assessment falls between the 10th and 90th percentiles for the infant's age.
D) AGA weight assessment is modified to consider intrauterine growth restriction (IUGR).

Question 21

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

Question 22

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?

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

Question 23

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 nurse's 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.

Question 24

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 ³95%.

Question 25

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.

Question 26

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.

Question 27

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?

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

Question 28

What is the nurse's initial action while caring for an infant with a slightly decreased temperature?

A) Immediately notify the physician.
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; a decreased body temperature is a sign of formula intolerance.

Question 29

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.

Question 30

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?

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

Question 31

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?

A) Swaddling
B) Nonnutritive sucking
C) Skin-to-skin contact with the mother
D) Sucrose
E) Acetaminophen

Question 32

A mother expresses fear about changing her infant's 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.

Question 33

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.