Maternity Nursing Chap 17

Question 1

True or False: Cardiopulmonary resuscitation for infants recommends performing ten cycles of five compressions and one ventilation (a 5:1 ratio) and then checking the brachial artery for a pulse.

Answer 1

False – 30:2 compression to ventilation ratio

Question 2

True or False: A delay of up to 2 hours for instilling a prophylactic antibiotic ointment into a newborn’s eyes is acceptable to facilitate parent infant attachment and boding.

Answer 2

True

Question 3

True or False: If an infant’s airway is obstructed by a foreign body, the infant should receive three chest thrusts followed by 2 back blows.

Answer 3

False – 4 chest compressions and 4 back blows

Question 4

True or False: Placing a dressed newborn under a radiant heat panel facilitates a more rapid stabilization of body temperature after birth.

Answer 4

False –

Question 5

True or False: The thermistor probe of a radiant heat panel should be taped to the right upper quadrant just below the costal margin (ribs).

Answer 5

True

Question 6

True or False: For the first 12 hours after birth a newborn’s temperature should be taken rectally until it has stabilized.

Answer 6

False – axillary

Question 7

True or False: Penicillin ointment is instilled into the newborn’s lower conjunctiva to prevent ophthalmia neonatorum.

Answer 7

False – erythromycin, tetracycline, or sliver nitrate

Question 8

True or False: Tympanic thermometers should not be used until after the first month of life.

Answer 8

False –

Question 9

True or False: Both breastfed and bottle fed babies should be fed every 3 to 4 hours during the day and throughout the night.

Answer 9

False – breastfed babies are fed on demand, 8 to 12 times in a 24 hour period. bottle fed babies are fed every 3 to 4 hours.

Question 10

True or False: The recommended site for intramuscular injections in the newborn is the vastus lateralis muscle.

Answer 10

True

Question 11

True or False: If bleeding is noted after a circumcision, the nurse should apply firm, constant pressure to the site until the physician arrives.

Answer 11

False – apply gentle pressure, if bleeding does not stop notify primary health care provider

Question 12

True or False: To facilitate obtaining a heel stick blood sample, the loose application of a warm, wet washcloth around the foot for 5 to 10 mins is sufficient to dilate the blood vessels in the heel.

Answer 12

True

Question 13

True or False: An alcohol swab should be used to apply pressure to the heel after a blood sample is obtained.

Answer 13

False – dry guaze.

Question 14

True or False: Pressure should be applied over an arterial or femoral vein puncture for at least 3 to 5 mins to prevent bleeding from the site.

Answer 14

True

Question 15

True or False: Before application of a U bag, the genitalia, perineum, and surrounding skin should be washed, dried, and sprinkled with talcum powder to prevent excoriation.

Answer 15

False –

Question 16

True or False: Nonnutritive sucking with a pacifier or finger should be discouraged in the newborn because it leads to malformation of the jaw and dependency.

Answer 16

False –

Question 17

True or False: A newborn’s serum glucose level should be 40 mg/dL or higher.

Answer 17

True

Question 18

True or False: Hepatitis B vaccine should only be administered to newborns exposed to the hepatitis B virus.

Answer 18

False – recommended for all infants

Question 19

True or False: The prone position should not be used for the first few months of life because it has been associated with an increase in the risk for sudden infant death syndrome.

Answer 19

True

Question 20

True or False: Late preterm infants are those born at 39 0/7 weeks of gestation or more.

Answer 20

False –

Question 21

True or False: An apgar score of 9 indicates that the newborn is having minimal or no difficulty adjusting to extrauterine life.

Answer 21

True

Question 22

True or False: The wink reflex can be used to assess anal sphincter response.

Answer 22

True

Question 23

True or False: Screening for hypothyroidism involves assessing the newborn’s level of T4.

Answer 23

True

Question 24

True or False: When caring for the newborn, wearing gloves is the single most important measure in preventing neonatal infection.

Answer 24

False – hand washing

Question 25

True or False: When using a bulb syringe after birth, the newborn’s nose should be suctioned before her or his mouth.

Answer 25

False – mouth is suctioned first.

Question 26

True or False: The ointment used for prevention of newborn ophthalmic infection should be flushed out of eyes with normal saline 5 mins after instillation.

Answer 26

False –

Question 27

True or False: Infants should be placed in a rear facing car seat that is secured in the back seat of the car.

Answer 27

True

Question 28

During a circumcision the ________ of the glans penis is removed. Currently the decision to perform this elective procedure is left up to the ________.

Answer 28

• prepuce (foreskin)

- parents

Question 29

_________ or _________ ointment is used to prevent ophthalmia neonatorum. It should be instilled into the _________ of each eye.

Answer 29

• tetracycline
• erythromycin
• lower conjunctiva

Question 30

_________ is administered intramuscularly to newborns to prevent hemorrhage. It is administered in a dose of ______ using a _______-gauge, _______-inch needle.

Answer 30

• vitamin K
• 0.5 to 1 mg
• 25
• 5/8

Question 31

The umbilical cord site should be assessed for _____, _____, and ______ at each diaper change.

Answer 31

• edema
• redness
• purulent drainage
• erythromycin solution
• triple blue dye
• alcohol

Question 32

An infant born before completion of 37 weeks of gestation, regardless of birth weight, is referred to as _______ or __________.

Answer 32

• preterm

- premature

Question 33

An infant born between the beginning of week 38 and the end of week 42 gestation is referred to as __________.

Answer 33

-term

Question 34

An infant who is born after the completion of week 42 of gestation is referred to as __________ or ________.

Answer 34

• postterm

- postdate

Question 35

An infant born after 42 weeks of gestation and showing the effects of progressive placental insufficiency is referred to as ________.

Answer 35

-postmature

Question 36

An infant whose weight is above the 90th percentile ( or 2 or more standard deviations above the norm) at any week is referred to as _________.

Answer 36

-large for gestational age (LGA)

Question 37

An infant whose weight falls between the 10th and the 90th percentiles for his or her gestational age is referred to as ____________.

Answer 37

-appropriate for gestational age (AGA)

Question 38

An infant whose weight is below the 10th percentile (or 2 or more standard deviations below the norm) at any week is referred to as ___________.

Answer 38

-small for gestational age (SGA)

Question 39

Signs for neuromuscular maturity (New Ballard Scale):

Answer 39

• assess such signs as posture, arm recoil, popliteal angle, scarf sign, heel to ear
• note that the full term newborn is more flexed and resists efforts to pull limbs in a certain direction (e.g., bringing heel to ear or elbow across sternum)

Question 40

Signs for physical maturity (New Ballard Scale):

Answer 40

-assess such signs as skin condition, presence of lanugo, plantar creases, breast size, eye and ear formation, condition of genitalia

Question 41

Designation of AGA, LGA, and SGA (New Ballard Scale):

Answer 41

• first, determine gestational age using the new Ballard scale
• second, measure newborn’s head circumference, length, weight
• third, plot estimated gestational age and measurements on graph to determine classification

Question 42

A newborn male is estimated to be 40 weeks of gestation following an assessment using the New Ballard Scale. A Ballard Scale finding consistent with this newborn’s full term status would be:

a. apical pulse rate of 120 beats/min, regular, and strong
b. popliteal angle of 160 degrees
c. weight of 3200 g, placing him at the 50th percentile
d. thinning of lanugo with some bald areas

Answer 42

d.

• thinning of the lungo with bald spots is consistent with full term status
• pulse and weight are not part of the Ballard scale
• the popliteal angle for a full term newborn would be 100 degrees or less

Question 43

The nurse evaluates the laboratory test results of a newborn who is 4 hours old. Which of the following results would require notification of the pediatrician?

a. hemoglobin, 20 g/dL
b. hematocrit, 54%
c. glucose, 34 mg/dL
d. direct bilirubin, 0.6 mg/dL

Answer 43

c.

• the hemoglobin should be 14 to 24 g/dL
• the hematocrit should be 44% to 64%
• glucose shoudl be 40 to 60 mg/dL
• bilirubin should be 0 to 1 mg/dL

Question 44

A newborn male has been designated as large for gestational age. His mother was diagnosed with gestational diabetes late in her pregnancy. The nurse should be alert for signs of hypoglycemia. Which of the following assessment findings are consistent with a diagnosis of hypoglycemia?

a. unstable body temperature
b. cyanosis
c. edema of the extremities
d. abdominal distention

Answer 44

b.

• signs of hypoglycemia include cyanosis along with apnea, jitteriness and twitching, irregular respirations, high pitched cry, difficulty feeding, hunger lethargy, eye rolling, and seizures
• C and D are consistent with hypocalcemia

Question 45

A radiant warmer will be used to help a newborn girl stabilize her temperature. The nurse implementing this care measure should:

a. undress and dry the infant before placing her under the warmer
b. set the control panel between 35* and 38* C
c. place the thermistor probe on the left side of her chest just below her nipple
d. assess her rectal temperature every hour until her temperature stabilizes

Answer 45

a.

Question 46

A newborn male has been scheduled for a circumcision using the Gomco clamp technique. Essential nursing measures as part of this surgical procedure include which one of the following?

a. feed the infant just before the procedure to help him remain relaxed and quiet
b. apply petroleum jelly to the site with each diaper change
c. check the penis for bleeding every 15 mins for the first 4 hours
d. teach the parents to remove the yellowish exudate that forms over the glans using a diaper wipe

Answer 46

b.

• the infant should be NPO for up to 4 hours to prevent vomiting and aspiration
• site should be checked every 12 hours
• the yellow exudate is a protective film that forms in 24 hours and should not be removed