Chapter 24: Nursing Care of the Newborn and Family Lowdermilk: Maternity & Women’s Health Care, 11th Edition

TEST BANK FOR MATERNITY & WOMEN’S HEALTH CARE 11TH EDITION BY LOWDERMILK Chapter 24: Nursing Care of the Newborn and Family Lowdermilk: Maternity & Women’s Health Care, 11th Edition MULTIPLE CHOICE 1. An infant boy was delivered minutes ago. The nurse is conducting the initial assessment. Part of the assessment includes the Apgar score. When should the Apgar assessment be 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 CORRECT ANSWER: C Apgar scoring is performed at 1 minute and at 5 minutes after birth. Scoring may continue at 5-minute intervals if the infant is in distress and requires resuscitation efforts. The Apgar score is performed on all newborns. Apgar score can be completed by the nurse or the birth attendant. The Apgar score permits a rapid assessment of the newborn‘s trCORRECT ANSWERition to extrauterine life. An interval of every 15 minutes is too long to wait to complete this assessment. DIF: Cognitive Level: Understand REF: p. 550 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 2. A new father wants to know what medication was put into his infant‘s eyes and why it is needed. How does the nurse explain the purpose of the erythromycin (Ilotycin) ophthalmic ointment? a. Erythromycin (Ilotycin) ophthalmic ointment destroys an infectious exudate caused by Staphylococcus that could make the infant blind. b. This ophthalmic ointment prevents gonorrheal and chlamydial infection of the infant‘s eyes, potentially acquired from the birth canal. c. Erythromycin (Ilotycin) prevents potentially harmful exudate from invading the tear ducts of the infant‘s eyes, leading to dry eyes. d. This ointment prevents the infant‘s eyelids from sticking together and helps the infant see. CORRECT ANSWER: B The nurse should explain that prophylactic erythromycin ophthalmic ointment is instilled in the eyes of all neonates to prevent gonorrheal and chlamydial infection that potentially could have been acquired from the birth canal. This prophylactic ophthalmic ointment is not instilled to prevent dry eyes and has no bearing on vision other than to protect against infection that may lead to vision problems. DIF: Cognitive Level: Apply REF: p. 568 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 3. A nurse is assessing a newborn girl who is 2 hours old. Which finding warrants a call to the health care provider? a. Blood glucose of 45 mg/dl using a Dextrostix screening method b. Heart rate of 160 beats per minute after vigorously crying c. Laceration of the cheek d. Passage of a dark black-green substance from the rectum CORRECT ANSWER: C Accidental lacerations can be inflicted by a scalpel during a cesarean birth. They are most often found on the scalp or buttocks and may require an adhesive strip for closure. Parents would be overly concerned about a laceration on the cheek. A blood glucose level of 45 mg/dl and a heart rate of 160 beats per minute after crying are both normal findings that do not warrant a call to the physician. The passage of meconium from the rectum is an expected finding in the newborn. DIF: Cognitive Level: Understand REF: p. 570 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 4. What is the rationale for the administration of vitamin K to the healthy full-term newborn? a. Most mothers have a diet deficient in vitamin K, which results in the infant being deficient. b. Vitamin K prevents the synthesis of prothrombin in the liver and must be administered by injection. c. Bacteria that synthesize vitamin K are not present in the newborn‘s intestinal tract. d. The supply of vitamin K in the healthy full-term newborn is inadequate for at least 3 to 4 months and must be supplemented. CORRECT ANSWER: C 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. DIF: Cognitive Level: Understand REF: pp. 568-569 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 5. The nurse is using the New 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 CORRECT ANSWER: A Term infants typically have a flexed posture. Abundant lanugo; smooth, pink skin with visible veins; and faint red marks are usually observed on preterm infants. DIF: Cognitive Level: Understand REF: pp. 553, 554 TOP: Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance