Chapter 26: Nursing Care of the Newborn and Family

Question 1

1. An infant was born just a few minutes ago and the nurse is assessing the Apgar score. When is the Apgar score performed?
   a. It is performed only if the newborn is in obvious distress.
   b. It is performed once by the primary health care provider, just after the birth.
   c. It is performed at least twice, 1 minute and 5 minutes after birth.
   d. It is performed every 15 minutes during the newborn’s first hour after birth.

Answer 1

ANS: C
Apgar scoring is performed at 1 minute and 5 minutes after birth. Scoring may continue at 5-minute intervals if the infant is in distress and requires resuscitation efforts.

Question 2

2. A new parent wants to know what medication was put into their infant’s eyes and why it is needed. What does the nurse explain to the parent about the purpose of the erythromycin ophthalmic ointment?
   a. It destroys an infectious exudate caused by Staphylococcus that could make the
   infant blind.
   b. It prevents gonorrheal and chlamydial infection of the infant’s eyes that is
   potentially acquired from the birth canal.
   c. It prevents potentially harmful exudate from invading the tear ducts of the infant’s
   eyes, leading to dry eyes.
   d. It prevents the infant’s eyelids from sticking together and helps the infant see.

Answer 2

ANS: B
The purpose of the erythromycin ophthalmic ointment is to prevent gonorrheal and chlamydial infection of the infant’s eyes that is potentially acquired from the birth canal. Prophylactic ophthalmic ointment is instilled in the eyes to prevent gonorrheal or chlamydial infection. Prophylactic ophthalmic ointment is not instilled to prevent dry eyes. Prophylactic ophthalmic ointment has no bearing on vision other than to protect against infection that may lead to vision problems.

Question 3

3. The nurse is using the Ballard scale to determine the gestational age of a newborn. Which 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

Answer 3

ANS: A
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 preterm infants.

Question 4

4. A 3800 g infant was born vaginally at 39 weeks after a 30-minute second stage. There was a nuchal cord. After birth, the infant had petechiae over the face and upper back. Which information would be accurate to be given to the infant’s parents about petechiae?
   a. They are benign if they disappear within 48 hours of birth.
   b. They result from increased blood volume.
   c. They should always be further investigated.
   d. They usually occur with forceps assisted birth.

Answer 4

ANS: A
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 for the family to be alarmed. Petechiae usually occur with a breech presentation vaginal birth.

Question 5

5. What is the most important appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy via ultraviolet lights?
   a. Ensure the newborn is removed from phototherapy during feeding.
   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 2 hours.

Answer 5

ANS: C
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. 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 but this is not the priority. The newborn should be removed from phototherapy for feeding and interaction with parents but this is not the priority.

Question 6

6. Early this morning, an infant boy was circumcised using the PlastiBell method. When should the nurse tell the mother that she and their infant can be discharged?
   a. The bleeding stops completely.
   b. Yellow exudate forms over the glans.
   c. The PlastiBell rim falls off.
   d. The infant voids

Answer 6

ANS: D
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 exudates cover the glans penis within 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 7

7. A mother expresses fear about changing their infant’s diaper after he is circumcised with a Gomco clamp. What does the patient need to be taught, in order to take care of the infant when they go 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.

Answer 7

ANS: C
Cleansing the penis gently with water and putting petroleum jelly around the glans after each diaper change is appropriate when caring for an infant who has had a circumcision. 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. Yellow exudates cover the glans penis within 24 hours after the circumcision. This is part of normal healing and not an infective process. The exudates should not be removed.

Question 8

8. What should the nurse be aware of when preparing to administer a hepatitis B vaccine to a newborn?
   a. Obtain a syringe with a 25-gauge, 16-mm (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.

Answer 8

ANS: A
The hepatitis B vaccine should be administered with a 25-gauge, 16-mm (5/8-inch) needle. In some provinces hepatitis B vaccination is recommended for all infants at birth, in others it is given when the child is a preteen. 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.

Question 9

9. Which range, in g/L, represents the normal hemoglobin of a healthy full-term infant?
   a. 50 to 95
   b. 120 to 150
   c. 140 to 240
   d. 160 to 260

Answer 9

ANS: C
The normal range of hemoglobin in a term newborn is 140 to 240 g/L.

Question 10

10. What is the main reason that nurses wear gloves when handling the newborn at birth?
    a. To protect the baby from infection
    b. It is part of the Apgar protocol
    c. To protect the nurse from contamination by the newborn
    d. Because the nurse has primary responsibility for the baby during the first 2 hours

Answer 10

ANS: C
Gloves are worn to protect the nurse from infection until the blood and amniotic fluid are cleaned off the newborn.

Question 11

11. While evaluating the reflexes of a newborn, the nurse notes that with a loud noise the newborn symmetrically abducts and extends their arms, their fingers fan out and form a C with the thumb and forefinger, and they have a slight tremor. How would the nurse document this positive finding?
    a. Tonic neck reflex
    b. Glabellar (Myerson) reflex
    c. Babinski reflex
    d. Moro reflex

Answer 11

ANS: D
The characteristics displayed by the infant are associated with a positive Moro reflex. The tonic neck reflex occurs when the infant extends the leg on the side to which the infant’s head simultaneously turns. The glabellar reflex is elicited by tapping on the infant’s head while the eyes are open. A characteristic response is blinking for the first few taps. The Babinski reflex occurs when the sole of the foot is stroked upward along the lateral aspect of the sole and then across the ball of the foot. A positive response occurs when all the toes hyperextend, with dorsiflexion of the big toe.

Question 12

12. What would an Apgar score of 10 at 1 minute after birth indicate?
    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 score predicts a future free of neurological problems.
    d. The infant will have no difficulty adjusting to extrauterine life, but should be
    assessed again at 5 minutes after birth.

Answer 12

ANS: D
An initial Apgar score of 10 is a good sign of healthy adaptation; however, it must be repeated at the 5-minute mark.

Question 13

13. What should the nurse be aware of with regard to umbilical cord care?
    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.

Answer 13

ANS: 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 the bleeding does not stop, 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.

Question 14

14. In the classification of newborns by gestational age and birth weight, which is the appropriate for gestational age (AGA) weight?
    a. It falls between the twenty-fifth and seventy-fifth percentiles for the infant’s age.
    b. It depends on the infant’s length and the size of the head.
    c. It falls between the tenth and ninetieth percentiles for the infant’s age.
    d. It should be modified to consider intrauterine growth restriction (IUGR).

Answer 14

The AGA range is a large one: between the tenth and the ninetieth percentiles for infant age. The infant’s length and size of the head are measured, but do not affect the normal weight designation. IUGR applies to the fetus, not the newborn’s weight.

Question 15

15. Which statement applies to a complete physical examination within 24 hours after birth?
    a. The parents are excused to reduce their normal anxiety.
    b. The nurse can gauge the newborn’s maturity level by assessing the infant’s
    general appearance.
    c. It is ideally completed immediately after birth.
    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.

Answer 15

ANS: B
The nurse will be looking at skin colour, 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. The complete exam is not done immediately at birth; the infant’s temperature must be stabilized. The second sound is higher and sharper than the first.

Question 16

16. Which type of blood should be used for genetic screening?
    a. Maternal venous
    b. Maternal cord blood
    c. Fetal cord blood
    d. Infant capillary blood

Answer 16

ANS: D
Genetic screening should be carried out on newborn venous or capillary blood.

Question 17

17. Which should the nurse explain to the parents that will assist them with their decision related to circumcision?
    a. The nurse explains the pros and cons of the procedure during the prenatal period.
    b. The Canadian Paediatric Society (CPS) recommends that all newborn males 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.

Answer 17

ANS: A
Many parents find themselves making the decision during the pressure of labour. The CPS and other professional organizations note the benefits but stop short of recommendation for routine circumcision. Circumcision is painful and must be managed with environmental, nonpharmacological, and pharmacological measures. After the procedure the infant may be fussy for several hours, or he may be sleepy and difficult to awaken for feeding.

Question 18

18. The normal term newborn 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, which is important that the nurse teach them to do?
    a. Avoid suctioning the nares.
    b. Insert the compressed bulb into the centre of the mouth.
    c. Suction the mouth first.
    d. Remove the bulb syringe from the crib when finished.

Answer 18

ANS: C
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. After compression of the bulb it should be inserted into one side of the mouth. If it is inserted into the centre 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

19. Which principle applies to a newborn bath?
    a. Cleanse eyes from outer canthus to inner.
    b. Complete the bath from clean to dirty.
    c. Finish the bath with fresh water and cleaning the infant’s face.
    d. Wash genitals first, then diaper and continue the bath.

Answer 19

ANS: B
Always work from clean to dirty. Start with the face, neck, and ears first. Do not use soap on the face. Cleanse the eyes from the inner canthus outward, using separate parts of a clean washcloth for each eye.

Question 20

20. Which newborn reflex is elicited by stroking the lateral sole of the newborn’s foot from the heel to the ball of the foot?
    a. Babinski
    b. Tonic neck
    c. Stepping
    d. Plantar grasp

Answer 20

ANS: A
The Babinski reflex causes the toes to flare outward and the big toe to dorsiflex. The tonic neck reflex (also called the fencing reflex) refers to the posture assumed by newborns when in a supine position. The stepping reflex occurs when infants are held upright with their heel touching a solid surface and the infant appears to be walking. Plantar grasp reflex is similar to the palmar grasp reflex: when the area below the toes is touched, the infant’s toes curl over the nurse’s finger.

Question 21

21. A nurse is performing a gestational age and physical assessment on the newborn. The newborn 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.

Answer 21

ANS: C
The presence of excessive saliva in a neonate should alert the nurse to the possibility of tracheoesophageal fistula or esophageal atresia.

Question 22

22. The nurse’s initial action when caring for a newborn with a slightly decreased temperature is to
    a. notify the health care provider immediately.
    b. place a cap on the newborn’s head.
    c. take the newborn to the nursery and observe for the next 4 hours.
    d. change the formula because this is a sign of formula intolerance.

Answer 22

ANS: B
Keeping the head well covered with a cap will prevent further heat loss from the head, and having the mother place the infant skin to skin should increase the infant’s temperature. Nursing actions are needed first to correct the problem. If the problem persists after interventions, notification may then be necessary. A slightly decreased temperature can be treated in the mother’s room. This would be an excellent time for parent teaching on prevention of cold stress. Mild temperature instability is an expected deviation from normal during the first days as the infant adapts to external life.

Question 23

23. 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 their abdomen to sleep.

Answer 23

ANS: D
The infant should be laid down to sleep on their back for better breathing and to prevent sudden infant death syndrome. 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. Infants should always be placed “back to sleep” and allowed tummy time to play, to prevent plagiocephaly.

Question 24

24. To prevent the abduction of newborns from the hospital, the nurse should
    a. instruct the mother not to give their 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 them in the halls.
    d. restrict the amount of time newborns are out of the nursery.

Answer 24

ANS: 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 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, so 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 most hospitals do not have newborn nurseries.

Question 25

25. A 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.

Answer 25

ANS: C
Bacteria that synthesize vitamin K are not present in the newborn’s intestinal tract. 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 26

1. As part of discharge teaching, which should nurses tell parents about in relation to their baby? (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, water beds, and beanbag chairs.
   d. Avoid letting the infant sleep on his or her back.
   e. Do not use a pacifier when the baby is put to sleep.
   f. Ensure the rear-facing car seat is placed in the front seat with the air bag on.

Answer 26

ANS: A, B, C
The infant should be laid down to sleep on his or her back for better breathing and to prevent sudden infant death syndrome. 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. There is compelling evidence that pacifier use helps prevent SIDS. It is suggested that parents consider offering a pacifier for naps and bedtime. Rear-facing infant seats should not be placed in the front seat unless the air bag has been deactivated

Question 27

2. When eliciting newborn reflexes, which is true about the Babinski reflex? (Select all that apply.)
   a. Place infant prone on a flat surface and run finger down back lateral to the spine
   to elicit the Babinski reflex.
   b. Absence of Babinski reflex requires neurological evaluation.
   c. Babinski reflex usually disappears by 1 year of age.
   d. Response to Babinski reflex is the trunk flexes and the pelvis swings to the
   stimulated side.
   e. A positive Babinski is hyperextension of all toes with dorsiflexion of the big toe.
   f. Lower limbs should extend when the Babinski reflex is elicited.

Answer 27

ANS: B, C, E
The Babinski reflex is elicited by stroking the foot beginning at the heel and upward along the lateral aspect of the sole, then moving finger across the ball of the foot. It normally disappears by 1 year of age. A positive Babinski is hyperextension of all toes with dorsiflexion of the big toe. Placing the infant prone on a flat surface and running a finger down the back lateral to the spine is done to elicit the truncal incurvation reflex. Response to the truncal incurvation reflex is that the trunk flexes and the pelvis swings to the stimulated side. Lower limbs extending usually happens when eliciting the magnet reflex.

Question 28

3. Pain should be assessed regularly in all newborns. If the newborn is displaying physiological or behavioural cues indicating pain, measures should be taken to manage the pain. Examples of nonpharmacological pain management techniques include (Select all that apply.)
   a. swaddling.
   b. nonnutritive sucking.
   c. skin-to-skin contact with the mother.
   d. sucrose.
   e. acetaminophe

Answer 28

ANS: A, B, C, D
Swaddling, nonnutritive sucking, skin-to-skin contact with the mother, and sucrose are all appropriate nonpharmacological techniques used to manage pain in newborns. Acetaminophen is a pharmacological method of treating pain.

Question 29

4. Hearing loss is one of the genetic disorders that may be screened for in the newborn period. Auditory screening of all newborns within the first month of life is recommended by the Canadian Paediatric Society. 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. mandated by all provinces.

Answer 29

ANS: A, C, D
New parents are often anxious regarding this test and the impending results; however, it is not the reason for the screening to be performed. Auditory screening is usually done before hospital discharge is most provinces. It is important for the nurse to ensure that the infant receives the appropriate testing and that the test is fully explained to the parents. For infants who are referred for further testing and follow-up, it is important for the nurse to provide further explanation and emotional support. 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 they still do not pass the test, they should have a full audiologic and medical evaluation by 3 months of age. If necessary, the infant should be enrolled in early intervention by 6 months of age.

Question 30

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

Answer 30

ANS: 5
Each of the five signs the nurse noted would score an Apgar of 1 for a total of 5. Signs include heart rate, respiratory effort, muscle tone, reflex irritability, and colour. The highest possible Apgar score is 10.