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?

Accepted Answer

The infant should be observed for urination after the circumcision.Bleeding is a common complication after circumcision,and the nurse will check the penis for 12 hours after a circumcision to assess and provide appropriate interventions for the prevention and treatment of bleeding.Yellow exudate covers the glans penis in 24 hours after the circumcision and is part of normal healing; yellow exudate is not an infective process.The PlastiBell plastic rim (bell)remains in place for approximately a week and falls off when healing has taken place.

Question 2

What is the primary rationale for nurses wearing gloves when handling the newborn?

Accepted Answer

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.

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?

Accepted Answer

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 infant's 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.

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?

Accepted Answer

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.

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?

Accepted Answer

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 mother's 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.

Question 6

The nurse is teaching new parents about metabolic screening for the newborn.Which statement is most helpful to these clients?

Accepted Answer

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 infant's 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.

Question 7

Which explanation will assist the parents in their decision on whether they should circumcise their son?

Accepted Answer

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.

Question 8

A nurse is assessing a newborn girl who is 2 hours old.Which finding warrants a call to the health care provider?

Accepted Answer

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.

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?

Accepted Answer

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 infant's 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.

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?

Accepted Answer

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.

Question 11

The nurse is completing a physical examination of the newborn 24 hours after birth.Which component of the evaluation is correct?

Accepted Answer

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.

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?

Accepted Answer

The infant's 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.

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?

Accepted Answer

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.

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?

Accepted Answer

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.

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?

Accepted Answer

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.

Question 16

What is the rationale for the administration of vitamin K to the healthy full-term newborn?

Accepted Answer

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.

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?

Accepted Answer

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.

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?

Accepted Answer

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 newborn's transition to extrauterine life.An interval of every 15 minutes is too long to wait to complete this assessment.

Question 19

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

Accepted Answer

The HBV vaccine should be administered in the vastus lateralis muscle at childbirth with a 25-gauge,5/8-inch needle and is recommended for all infants.If the infant is born to an infected mother who is a chronic HBV carrier,then the hepatitis vaccine and HBV immunoglobulin should be administered within 12 hours of childbirth.

Question 20

Which statement accurately describes an appropriate-for-gestational age (AGA)weight assessment?

Accepted Answer

An AGA weight falls between the 10th and 90th percentiles for the infant's age.The AGA range is larger than the 25th and 75th percentiles.The infant's length and head size are measured,but these measurements do not affect the normal weight designation.IUGR applies to the fetus,not to the newborn's weight.

Quiz 24: Nursing Care of the Newborn and Family