Maternal-Newborn Care
Quiz:
1. A nurse is caring for a term newborn who has just had a circumcision using the Gomco
clamp technique. Which of the following instructions should the nurse include when
teaching the parents to care for the site? (select all that apply.)
a. Apply petroleum jelly to the penis for the first 24 hr.
b. Cleanse the penis with warm water and mild soap
c. Apply gentle pressure from a sterile gauze pad to control slight bleeding
d. Gently wipe away any yellow exudate on the penis
e. Apply the diaper loosely over the penis
2. A patient who is 1 day postpartum tells the nurse that she is concerned about her
newborn receiving enough nourishment from breastfeeding. The nurse should explain
that she should look for which of the following as a sign of adequate nutrition?
a. The newborn feeds at least six times in 24 hr.
b. The newborn has six wet diapers and three stools per day
c. The milk supply is plentiful by the newborn’s second day
d. The newborn has returned to his birth weight 6 to 8 days following delivery
3. A nurse is performing umbilical cord care for a term newborn. Which of the following
findings requires further assessment and intervention?
a. Blackening of the stump
b. Redness at the base
c. Clear gel at the tip
d. Hardening of the stump
4. A nurse is performing a gestational age assessment using the New Ballard Score for
newborn maturity rating. Which of the following findings indicates that the newborn is
preterm?
a. Flexion of the extremities at rest
b. Creases over the entire plantar surface
c. Leathery skin
d. Flat areola
5. A nurse is caring for a patient who is in labor and has pain in her lower back because the
fetal head is in a posterior position. Which of the following nonpharmacological pain
management techniques is likely to be most effective in relieving this type of pain?
a. Counterpressure
b. Effleurage
c. Therapeutic touch
d. Breathing techniques
6. A nurse is teaching the parents of a term newborn how to bathe him. Which of the
following instructions should the nurse include?
a. Bathe him every day
b. Give him a bath after he has had a feeding.
c. Give him a sponge bath until his cord stump falls of
d. Clean his ears and nose with cotton swabs
, 7. A newborn delivered vaginally at term 1 min ago cried loudly at delivery, has a heart rate
of 140/min, has well flexed arms and legs, grimaces when the nurse rubs the soles of his
feet, and is pink with mild acrocyanosis. What apgar score should the nurse assign to this
newborn?
a. 8
8. A nurse is assessing a patient at a routine antepartum visit. For a rough estimate of the
number of gestational weeks the patient is at, the nurse should measure the number of
cm between which two anatomical landmarks?
a. The mons pubis and the xiphoid process
b. The top of the fundus and the umbilicus
c. The symphysis pubis and the top of the fundus
d. The mons pubis and the umbilicus
9. A nurse is assessing a patient who is 1 day postpartum and is not breastfeeding. The
nurse notes the patient’s breasts are engorged. Which of the following actions is
appropriate for the patient to take?
a. Applying ice packs
b. Wearing a loose-fitting bra
c. Pumping her breasts
d. Taking a warm shower
10. A nurse is assessing a patient who is at 20 weeks of gestation. She instructs the patient
to be sure to report headaches, blurred vision, and swelling of her hands because these
are indications of which of the following complications of pregnancy?
a. Gestational diabetes
b. Preeclampsia
c. Hyperemesis gravidarum
d. Abruptio placentae
Auscultating Fetal Heart Tones
Possible to hear fetal heart tones around the 10th or 11th week of gestation with an
ultrasound fetoscope or stethoscope.
o Regular fetoscope and stethoscope can transmit fetal heart tones at 18 to 20
weeks
To auscultate fetal heart tones:
o Apply conductive gel to the patient’s skin
o Position the device midline just above the symphysis pubis
o Apply firm pressure
o Move the device around slowly until you hear heart tones
o Count the fetal rate for 1 minute
Assess the quality and rhythm
The fetal heart typically beats 120 to 160 times a minute
Gestational Age Assessment
, To determine the approximate age, you will assess six neuromuscular and six physical
characteristics
The New Ballard Score
o Appropriate for newborns from 20 to 44 weeks of gestation
o Each parameter scores from a minus 2 to 5 with the cumulative score correlating
with a gestational age between 26 and 44 weeks
For newborns younter than 26 gestational weeks, perform the assessment sooner than
12 hours after birth.
For newborns beyond 26 gestational weeks, perform the examination within 96 hours of
birth. (best to perform the examination within 48 hours of birth)
The gestational assessment is important because it relates directly to the likelihood of
complications during the newborn period
o Lower scores correlate with prematurity
o Higher scores correlate with postmaturity.
Neuromuscular assessment components
o Posture
Assess posture for the degree of flexion of the extremitites
At term, they are moderately flexed at rest
Preterm show lesser degrees of flexion
o Square window
Assess square window by grasping the newborn’s forearm and gently
flexing the wrist toward the inner arm.
Do not allow rotation of the wrist
Measure the angle that forms where the hand meets the wrist
At term, the hand should touch the wrist
Preterm newborns show greater angles of flexion
Very preterm newborns have an angle of wrist flexion of 90
degrees or more
o Arm recoil
Measure arm recoil by first flexing and holding both forearms for 5
seconds, then extending the arms and hands fully at the newborn’s side.
Release the hands and allow the arms to recoil (return to flexion)
Term newborns demonstrate full recoil to a position of flexion while
preterm newborns show less flexion
Measure the arm at the elbow to determine the arm recoil score
o Popliteal angle
Press the newborns thigh against his abdomen, measure the popliteal
angle by moving the foot gently toward the head until you meet
resistance.
Measure the angle behind the knee in the popliteal area
Term newborns are less flexible with about a 90-degree angle.
Very preterm newborns, the leg straightens to a 180-degree angle
Quiz:
1. A nurse is caring for a term newborn who has just had a circumcision using the Gomco
clamp technique. Which of the following instructions should the nurse include when
teaching the parents to care for the site? (select all that apply.)
a. Apply petroleum jelly to the penis for the first 24 hr.
b. Cleanse the penis with warm water and mild soap
c. Apply gentle pressure from a sterile gauze pad to control slight bleeding
d. Gently wipe away any yellow exudate on the penis
e. Apply the diaper loosely over the penis
2. A patient who is 1 day postpartum tells the nurse that she is concerned about her
newborn receiving enough nourishment from breastfeeding. The nurse should explain
that she should look for which of the following as a sign of adequate nutrition?
a. The newborn feeds at least six times in 24 hr.
b. The newborn has six wet diapers and three stools per day
c. The milk supply is plentiful by the newborn’s second day
d. The newborn has returned to his birth weight 6 to 8 days following delivery
3. A nurse is performing umbilical cord care for a term newborn. Which of the following
findings requires further assessment and intervention?
a. Blackening of the stump
b. Redness at the base
c. Clear gel at the tip
d. Hardening of the stump
4. A nurse is performing a gestational age assessment using the New Ballard Score for
newborn maturity rating. Which of the following findings indicates that the newborn is
preterm?
a. Flexion of the extremities at rest
b. Creases over the entire plantar surface
c. Leathery skin
d. Flat areola
5. A nurse is caring for a patient who is in labor and has pain in her lower back because the
fetal head is in a posterior position. Which of the following nonpharmacological pain
management techniques is likely to be most effective in relieving this type of pain?
a. Counterpressure
b. Effleurage
c. Therapeutic touch
d. Breathing techniques
6. A nurse is teaching the parents of a term newborn how to bathe him. Which of the
following instructions should the nurse include?
a. Bathe him every day
b. Give him a bath after he has had a feeding.
c. Give him a sponge bath until his cord stump falls of
d. Clean his ears and nose with cotton swabs
, 7. A newborn delivered vaginally at term 1 min ago cried loudly at delivery, has a heart rate
of 140/min, has well flexed arms and legs, grimaces when the nurse rubs the soles of his
feet, and is pink with mild acrocyanosis. What apgar score should the nurse assign to this
newborn?
a. 8
8. A nurse is assessing a patient at a routine antepartum visit. For a rough estimate of the
number of gestational weeks the patient is at, the nurse should measure the number of
cm between which two anatomical landmarks?
a. The mons pubis and the xiphoid process
b. The top of the fundus and the umbilicus
c. The symphysis pubis and the top of the fundus
d. The mons pubis and the umbilicus
9. A nurse is assessing a patient who is 1 day postpartum and is not breastfeeding. The
nurse notes the patient’s breasts are engorged. Which of the following actions is
appropriate for the patient to take?
a. Applying ice packs
b. Wearing a loose-fitting bra
c. Pumping her breasts
d. Taking a warm shower
10. A nurse is assessing a patient who is at 20 weeks of gestation. She instructs the patient
to be sure to report headaches, blurred vision, and swelling of her hands because these
are indications of which of the following complications of pregnancy?
a. Gestational diabetes
b. Preeclampsia
c. Hyperemesis gravidarum
d. Abruptio placentae
Auscultating Fetal Heart Tones
Possible to hear fetal heart tones around the 10th or 11th week of gestation with an
ultrasound fetoscope or stethoscope.
o Regular fetoscope and stethoscope can transmit fetal heart tones at 18 to 20
weeks
To auscultate fetal heart tones:
o Apply conductive gel to the patient’s skin
o Position the device midline just above the symphysis pubis
o Apply firm pressure
o Move the device around slowly until you hear heart tones
o Count the fetal rate for 1 minute
Assess the quality and rhythm
The fetal heart typically beats 120 to 160 times a minute
Gestational Age Assessment
, To determine the approximate age, you will assess six neuromuscular and six physical
characteristics
The New Ballard Score
o Appropriate for newborns from 20 to 44 weeks of gestation
o Each parameter scores from a minus 2 to 5 with the cumulative score correlating
with a gestational age between 26 and 44 weeks
For newborns younter than 26 gestational weeks, perform the assessment sooner than
12 hours after birth.
For newborns beyond 26 gestational weeks, perform the examination within 96 hours of
birth. (best to perform the examination within 48 hours of birth)
The gestational assessment is important because it relates directly to the likelihood of
complications during the newborn period
o Lower scores correlate with prematurity
o Higher scores correlate with postmaturity.
Neuromuscular assessment components
o Posture
Assess posture for the degree of flexion of the extremitites
At term, they are moderately flexed at rest
Preterm show lesser degrees of flexion
o Square window
Assess square window by grasping the newborn’s forearm and gently
flexing the wrist toward the inner arm.
Do not allow rotation of the wrist
Measure the angle that forms where the hand meets the wrist
At term, the hand should touch the wrist
Preterm newborns show greater angles of flexion
Very preterm newborns have an angle of wrist flexion of 90
degrees or more
o Arm recoil
Measure arm recoil by first flexing and holding both forearms for 5
seconds, then extending the arms and hands fully at the newborn’s side.
Release the hands and allow the arms to recoil (return to flexion)
Term newborns demonstrate full recoil to a position of flexion while
preterm newborns show less flexion
Measure the arm at the elbow to determine the arm recoil score
o Popliteal angle
Press the newborns thigh against his abdomen, measure the popliteal
angle by moving the foot gently toward the head until you meet
resistance.
Measure the angle behind the knee in the popliteal area
Term newborns are less flexible with about a 90-degree angle.
Very preterm newborns, the leg straightens to a 180-degree angle
