Chapter 25 Nursing Care of the Newborn Flashcards Preview

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Flashcards in Chapter 25 Nursing Care of the Newborn Deck (21):

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.


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


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.

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. 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.


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

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.


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 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.

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.


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 (choose all that apply):
a. Swaddling.
b. Nonnutritive sucking.
c. Skin-to-skin contact with the mother.
d. Sucrose.
e. Acetaminophen.

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.


As part of their teaching function at discharge, nurses should tell parents that the baby’s respiration should be protected by all of the following procedures except:
a. Preventing exposure to people with upper respiratory tract infections.
b. Keeping the infant away from secondhand smoke.
c. Avoiding loose bedding, water beds, and beanbag chairs.
d. Not letting the infant sleep on his or her back.

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.


The nurse is discussing infant care as part of the mother-infant’s couplet discharge planning. The mother asks the nurse, “When will my baby’s cord fall off?” The nurse responds, “Your baby’s cord should fall off by ____________________ (weeks/days) after birth.”

ANS: 10-14 days


With regard 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.

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).


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 its 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.

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 higher and sharper than the first.


The nurse is performing a blood glucose test every 4 hours on an infant born to a diabetic mother. This is to assess the infant’s risk of hypoglycemia. The nurse becomes concerned if the infant’s blood glucose concentration falls below _____ mg/dl.

ANS: 36


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).

The AGA range is a large one: between the 10th and the 90th 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.


Nurses can help parents deal with the issue and fact of circumcision if they explain:
a. The pros and cons of the procedure during the prenatal period.
b. That the American Academy of Pediatrics (AAP) recommends that all newborn males 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.

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.


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.

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.


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 that 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.

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


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.

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.


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.

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. If the mother is a hepatitis B carrier, the vaccine should be given to the infant within 12 hours after birth.


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. The nurse would calculate an Apgar score of:
a. 4. c. 6.
b. 5. d. 7.

Each of the five signs the nurse noted would score a 1 on the Apgar scale, for a total of 5.


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.

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 in 24 hours after the circumcision. This is part of normal healing and not an infective process. The exudates should not be removed.


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. Because the nurse has primary responsibility for the baby during the first 2 hours.

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


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.

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


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.

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.