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Flashcards in Chapter 25 Deck (20):
1

An infant boy 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 obstetrician, 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.

C

2

A new father wants to know what medication was put into his infant’s eyes and why it is needed. What does the nurse explain to the father about the purpose of the Ilotycin 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.

B

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

A

4

A 3800 g infant was delivered 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 delivery.

A

5

A newborn is jaundiced and receiving phototherapy via ultraviolet bank lights. Which is an appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy?
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.

C

6

Early this morning, an infant boy was circumcised using the PlastiBell method. When should the nurse tell the mother that she and her 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.

D

7

A mother expresses fear about changing her infant’s diaper after he is circumcised. What does the woman need to be taught, in order 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.

C

8

When preparing to administer a hepatitis B vaccine to a newborn, what should the nurse know?
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.

A

9

Which range, in g/L, represents the normal hemoglobin of a healthy full-term infant?
a.
50 to 95
b.
125 to 150
c.
166 to 175
d.
195 to 205

C

10

What is the main reason that nurses wear gloves when handling the newborn at birth?
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.
Because the nurse has primary responsibility for the baby during the first 2 hours

C

11

At 1 minute after birth, the nurse assesses the 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. On the basis of these data, what would the nurse calculate as the Apgar score?
a.
4
b.
5
c.
6
d.
7

B

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 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.

D

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.

A

14

In the classification of newborns by gestational age and birth weight, the appropriate for gestational age (AGA) weight would be which of the following?
a.
It falls between the 25th and 75th 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 10th and 90th percentiles for the infant’s age.
d.
It should be modified to consider intrauterine growth restriction (IUGR).

C

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 neonate’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.

B

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

D

17

Nurses can help parents deal with the issue and fact of circumcision if they explain which of the following?
a.
They explain 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.

A

18

As part of their teaching function at discharge, nurses should tell parents that the baby’s respiration will not be protected by which one of the following procedures?
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

D

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 do which of the following?
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.

C

20

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.

B