Question 1

During the complete physical examination 24 hours after birth:

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 a chance to observe interactions.Blood pressure is not usually taken unless cardiac problems are suspected.The second sound is higher and sharper than the first.

Question 2

A newborn is jaundiced and is receiving phototherapy via ultraviolet bank lights.An appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy by this method is to:

Accepted Answer

The infant's eyes must be protected by an opaque mask to prevent overexposure to the light.Eye shields should cover the eyes completely but not occlude the nares.Lotions and ointments should not be applied to the infant because they absorb heat,and this can cause burns.The lights increase insensible water loss,placing the infant at risk for fluid loss and dehydration.Therefore,it is important that the infant be adequately hydrated.The infant should be turned every 2 hours to expose all body surfaces to the light.

Question 3

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 usually is seen on preterm infants.Smooth,pink skin with visible veins is seen on preterm infants.Faint red marks usually are seen on a preterm infant.

Question 4

As part of Standard Precautions,nurses wear gloves when handling the newborn.The chief reason is:

Accepted Answer

With the possibility of transmission of viruses such as hepatitis B virus (HBV)and human immunodeficiency virus (HIV)through maternal blood and amniotic fluid,the newborn must be considered a potential contamination source until proved 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 in order to complete the Apgar score assessment.The nurse assigned to the mother-baby couplet has primary responsibility regardless of whether or not she wears gloves.

Question 5

A nurse is assessing a newborn girl who is 2 hours old.What finding warrants a call to the physician?

Accepted Answer

A crepitant-like feeling when assessing the clavicles may indicate a fracture.If a fracture is suspected,the physician should be notified.A blood glucose level of 45 mg/dl is a normal finding and does not warrant a call to the physician.A heart rate of 160 beats/min after crying is a normal finding that does not warrant a call to the physician.The passage of meconium from the rectum is an expected finding in the newborn.

Question 6

An infant boy was born a few minutes ago.The nurse is conducting the initial assessment.Part of the assessment includes the Apgar score.The Apgar assessment is 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 7

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:

Accepted Answer

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

Question 8

In the classification of newborns by gestational age and birth weight,the appropriate-for- gestational age (AGA)weight:

Accepted Answer

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 do not affect the normal weight designation.IUGR applies to the fetus,not the newborn's weight.

Question 9

With regard to lab tests and diagnostic tests in the hospital after birth,nurses should be aware that:

Accepted Answer

If testing is done prior to 24 hours of age,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 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 prior to discharge from the hospital.

Question 10

When preparing to administer a hepatitis B vaccine to a newborn,the nurse should:

Accepted Answer

Administration of the hepatitis B vaccine should be given with a 25-gauge,5/8-inch needle.Hepatitis B vaccination is recommended for all infants.If the infant is born to an infected mother who is a chronic carrier,hepatitis vaccine and hepatitis B immune globulin should be administered within 12 hours of birth.Hepatitis B vaccine should be given in the vastus lateralis muscle.Hepatitis B vaccine can be given at birth.If the mother is a hepatitis B carrier,the vaccine should be given to the infant within 12 hours of birth.

Question 11

Although most blood specimens are drawn by laboratory technicians,nurses may be required to perform heelsticks to obtain blood for glucose monitoring or newborn screening.The most serious complication of an infant heelstick is necrotizing osteochondritis resulting from lancet penetration of the bone.To prevent this problem the stick should be made:

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 is not an appropriate site for a heelstick.The area below the fifth toe is not the correct site for a heelstick.

Question 12

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:

Accepted Answer

The presence of excessive saliva in a neonate should alert the nurse to the possibility of 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 presents with severe respiratory distress.

Question 13

At 1 minute after birth a nurse assesses an infant and notes a heart rate of 80 beats/min,some flexion of extremities,a weak cry,grimacing,and a pink body but blue extremities.The nurse calculates an Apgar score of:

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 14

Nurses can help parents deal with the issue and fact of circumcision if they explain:

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 15

The nurse administers vitamin K to the newborn for what reason?

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 16

An assessment tool for pain in newborns uses the acronym CRIES to identify behavioral indicators of pain.In the acronym:

Accepted Answer

In the acronym,C stands for crying;R is for requiring increased oxygen;I is for increased vital signs;E is for expression;and S is for sleeplessness.R is for requiring increased oxygen.E is for expression.S is for sleeplessness.

Question 17

A mother is changing the diaper of her newborn son.She notices that his scrotum appears large and swollen.She asks the nurse,"What is that?" The best response from the nurse is:

Accepted Answer

Explaining what a hydrocele is and its characteristics is the most appropriate response by the nurse.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 conditions,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 18

The normal term infant has little difficulty clearing its 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 easily be cleared 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:

Accepted Answer

The mouth should be suctioned first to prevent the infant from inhaling pharyngeal secretions by gasping as the nares are suctioned.The nasal passages should be suctioned one nostril at a time.The mouth should always be suctioned first.After compression of the bulb it should be inserted into one side of the mouth.If it is inserted into the center of the mouth,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 bulb syringe should remain in the crib so that it is easily accessible if needed again.

Question 19

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 erythromycin (Ilotycin)ophthalmic ointment is to:

Accepted Answer

The nurse should explain that erythromycin ophthalmic ointment prevents gonorrheal and chlamydial infection of the infant's eyes potentially acquired from the birth canal
Prophylactic ophthalmic ointment is instilled in the eyes of all neonates to prevent gonorrheal or chlamydial infection.Prophylactic ophthalmic ointment is not instilled to prevent dry eyes.It is instilled to prevent gonorrheal or chlamydial infection.Prophylactic ophthalmic ointment has no bearing on vision other than to protect against infection that may lead to vision problems.

Question 20

As part of the infant discharge teaching,the nurse is reviewing the use of the infant car safety seat.The nurse is teaching that:

Accepted Answer

An infant placed in the front seat could be severely injured by an air bag that has deployed during an accident.Infants should travel only in federally approved rear-facing safety seats secured in the rear seat.Infants should travel only in federally approved rear-facing safety seats even if traveling on a commercial vehicle.Infants should use a rear-facing car seat from birth to 20 pounds and to age 1 year.

Quiz 24: Nursing Care of the Newborn and Family