Chapter 23: Nursing Care of the Newborn and
FamilyPerry: Maternal Child Nursing Care, 6th
Edition Exam Question and Answer
1. 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 correct
answer:
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. correct
answer: ANS correct answer: 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 ettorts
2. 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 erythromycin ophthalmic ointment is to correct
answer:
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.-
correct answer: ANS correct answer: B
The purpose of the erythromycin 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
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17
,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.
3. 3. 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
correct answer:
a. are benign if they disappear within 48 hours of birth.
b. result from increased blood volume.
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17
, c. should always be further investigated.
d. usually occur with forceps delivery. correct answer: ANS correct answer:
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.
4. 4. 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 correct answer:
a. apply an oil-based lotion to the newborn's skin to prevent dying
and crack- ing.
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. correct answer: ANS
correct answer: 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.
5. 5. 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 correct answer:
a. the bleeding stops completely.
b. yellow exudate forms over the glans.
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17
FamilyPerry: Maternal Child Nursing Care, 6th
Edition Exam Question and Answer
1. 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 correct
answer:
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. correct
answer: ANS correct answer: 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 ettorts
2. 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 erythromycin ophthalmic ointment is to correct
answer:
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.-
correct answer: ANS correct answer: B
The purpose of the erythromycin 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
1/
17
,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.
3. 3. 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
correct answer:
a. are benign if they disappear within 48 hours of birth.
b. result from increased blood volume.
2/
17
, c. should always be further investigated.
d. usually occur with forceps delivery. correct answer: ANS correct answer:
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.
4. 4. 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 correct answer:
a. apply an oil-based lotion to the newborn's skin to prevent dying
and crack- ing.
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. correct answer: ANS
correct answer: 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.
5. 5. 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 correct answer:
a. the bleeding stops completely.
b. yellow exudate forms over the glans.
3/
17
