Perry - Chapter 23

Question 1

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

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

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 Ilotycin ophthalmic ointment is to:

a. Destroy an infectious exudate caused by Staphylococcus that could make the infant blind.
b. Prevent gonorrheal and chlamydial infection of the infant’s eyes potentially acquired from the birth canal.
c. Prevent potentially harmful exudate from invading the tear ducts of the infant’s eyes, leading to dry eyes.
d. Prevent the infant’s eyelids from sticking together and help the infant see.

Answer 2

ANS: B
The purpose of the Ilotycin ophthalmic ointment is to prevent 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. Prophylactic ophthalmic ointment has no bearing on vision other than to protect against infection that may lead to vision problems.

Question 3

The nurse is using the 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

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

A 3.8-kg infant was delivered vaginally at 39 weeks after a 30-minute second stage. There was a nuchal cord. After birth the infant is noted to have petechiae over the face and upper back. Information given to the infant’s parents should be based on the knowledge that petechiae:

a. Are benign if they disappear within 48 hours of birth.
b. Result from increased blood volume.
c. Should always be further investigated.
d. Usually occur with forceps delivery.

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 to alarm the family. Petechiae usually occur with a breech presentation vaginal birth.

Question 5

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

a. Apply an oil-based lotion to the newborn’s skin to prevent dying and cracking.
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 4 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. 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 6

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:

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 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 7

A mother expresses fear about changing her infant’s diaper after he is circumcised. What does the woman need to be taught to take care of the infant when she gets 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 are 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 in 24 hours after the circumcision. This is part of normal healing and not an infective process. The exudates should not be removed.

Question 8

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

a. Obtain a syringe with a 25-gauge, 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, 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.

Question 9

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:

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 9

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

Question 10

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

a. To protect the baby from infection.
b. That it is part of the Apgar protocol.
c. To protect the nurse from contamination by the newborn.
d. 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

The nurse’s initial action when caring for an infant with a slightly decreased temperature is to:

a. Notify the physician immediately.
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 because this is a sign of formula intolerance.

Answer 11

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 12

An Apgar score of 10 at 1 minute after birth would indicate a(n):

a. Infant having no difficulty adjusting to extrauterine life and needing no further testing.
b. Infant in severe distress who needs resuscitation.
c. Prediction of a future free of neurologic problems.
d. Infant having no difficulty adjusting to extrauterine life but who 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

With regard to umbilical cord care, nurses should be aware that:

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 calls 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

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

a. Fall between the 25th and 75th percentiles for the infant’s age.
b. Depend on the infant’s length and the size of the head.
c. Fall between the 10th and 90th percentiles for the infant’s age.
d. Be modified to consider intrauterine growth restriction (IUGR).

Answer 14

ANS: C
The AGA range is large: between the 10th and the 90th percentiles for the infant’s age. The infant’s length and size of the head are measured, but they do not affect the normal weight designation. IUGR applies to the fetus, not the newborn’s weight.

Question 15

During the complete physical examination 24 hours after birth:

a. The parents are excused to reduce their normal anxiety.
b. The nurse can gauge the neonate’s maturity level by assessing the infant’s general appearance.
c. Once often neglected, blood pressure is now routinely checked.
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 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 16

As related to laboratory tests and diagnostic tests in the hospital after birth, nurses should be aware that:

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 done before the infant is 24 hours old, it should be repeated at age 1 to 2 weeks.
d. Hearing screening is now mandated by federal law.

Answer 16

ANS: C
If done very early, genetic screening should be repeated. States all test for PKU and hypothyroidism, but other genetic defects are not universally covered. Federal law mandates newborn genetic screening, but not screening for hearing problems (although more than half the states do mandate hearing screening).

Question 17

Nurses can assist parents who are trying to decide whether their son should be circumcised by explaining:

a. The pros and cons of the procedure during the prenatal period.
b. That the American Academy of Pediatrics (AAP) recommends that all newborn boys be routinely circumcised.
c. That circumcision is rarely painful and any discomfort can be managed without medication.
d. That 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 labor. The AAP and other professional organizations note the benefits but stop short of recommendation for 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 18

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 his or her abdomen to sleep.

Answer 18

ANS: D
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. Per AAP guidelines, infants should always be placed “back to sleep” and allowed tummy time to play, to prevent plagiocephaly.

Question 19

The normal term infant 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, it is important that the nurse teach them to:

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.

Answer 19

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 the bulb 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 20

When teaching parents about mandatory newborn screening, it is important for the nurse to explain that the main purpose is to:

a. Keep the state records updated.
b. Allow accurate statistical information.
c. Document the number of births.
d. Recognize and treat newborn disorders early.

Answer 20

ANS: D
Early treatment of disorders will prevent morbidity associated with inborn errors of metabolism or other genetic conditions. Keeping records and reporting for statistical purposes are not the primary reason for the screening test. The number of births recorded is not reported from the newborn screening test.

Question 21

To prevent the abduction of newborns from the hospital, the nurse should:

a. Instruct the mother not to give her 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 him or her in the halls.
d. Restrict the amount of time infants are out of the nursery.

Answer 21

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 spend as little time in the nursery as possible.

Question 22

The 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 22

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 23

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.

Answer 23

ANS: A
The home visit is ideally scheduled within 72 hours after discharge. This timing allows early assessment and intervention for problems with feedings, jaundice, newborn adaptation, and maternal-infant interaction. Because home visits are expensive, they are not available in all geographic areas. Visits are usually 60 to 90 minutes in length to allow enough time for assessment and teaching. When jaundice is found, the nurse can discuss the implications and check the transcutaneous bilirubin level or draw blood for testing.

Question 24

Pain should be assessed regularly in all newborn infants. If the infant is displaying physiologic or behavioral cues indicating pain, measures should be taken to manage the pain. Examples of nonpharmacologic pain management techniques include (Select all that apply):

a. Swaddling.
b. Nonnutritive sucking.
c. Skin-to-skin contact with the mother.
d. Sucrose.
e. Acetaminophen.

Answer 24

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

Question 25

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 American Academy of Pediatrics. 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. Recommendation by the Joint Committee on Infant Hearing.

Answer 25

ANS: A, C, D, E
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. 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 26

At 1 minute after birth, the nurse assesses the infant and notes a heart rate of 80 beats/minute, 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 26

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 color. The highest possible Apgar score is 10.