Chapter 23: Nursing Care of the
Newborn & Family Perry: Maternal Child
Nursing Care, 6th Edition 2024-2025.
Questions & Answers. Graded A+.
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:
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. - ANSANS: 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 efforts
1. 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: (Select
all that apply.)
a. swaddling.
b. nonnutritive sucking.
c. skin-to-skin contact with the mother.
d. sucrose.
e. acetaminophen. - ANSANS: 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.
10. The nurse's initial action when caring for an infant with a slightly decreased
temperature is to:
a. notify the physician immediately.
b. place a cap on the infant's head.
c. tell the mother that the infant must be kept in the nursery and observed for the next 4
hours.
d. change the formula because this is a sign of formula intolerance. - ANSANS: B
Keeping the head well covered with a cap will prevent further heat loss from the head,
and having the mother place the infant skin to skin should increase the infant's
temperature. Nursing actions are needed first to correct the problem. If the problem
persists after interventions, notification may then be necessary. A slightly decreased
temperature can be treated in the mother's room. This would be an excellent time for
, parent teaching on prevention of cold stress. Mild temperature instability is an expected
deviation from normal during the first days as the infant adapts to external life.
11. 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 who 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. - ANSANS: D
An initial Apgar score of 10 is a good sign of healthy adaptation; however, it must be
repeated at the 5-minute mark.
12. With regard to umbilical cord care, nurses should be aware that:
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. - ANSANS: A
The cord stump is an excellent medium for bacterial growth. The nurse should first
check the clamp (or tie) and apply a second one. If the bleeding does not stop, the
nurse calls for assistance. The cord clamp is removed after 24 hours when it is dry. The
average cord separation time is 10 to 14 days.
13. 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). - ANSANS: C
The AGA range is large: between the 10th and the 90th percentiles for the infant's age.
The infant's length and size of the head are measured, but they do not affect the normal
weight designation. IUGR applies to the fetus, not the newborn's weight.
14. 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 the infant's 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. - ANSANS: B
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 is higher and sharper than the first.
Newborn & Family Perry: Maternal Child
Nursing Care, 6th Edition 2024-2025.
Questions & Answers. Graded A+.
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:
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. - ANSANS: 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 efforts
1. 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: (Select
all that apply.)
a. swaddling.
b. nonnutritive sucking.
c. skin-to-skin contact with the mother.
d. sucrose.
e. acetaminophen. - ANSANS: 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.
10. The nurse's initial action when caring for an infant with a slightly decreased
temperature is to:
a. notify the physician immediately.
b. place a cap on the infant's head.
c. tell the mother that the infant must be kept in the nursery and observed for the next 4
hours.
d. change the formula because this is a sign of formula intolerance. - ANSANS: B
Keeping the head well covered with a cap will prevent further heat loss from the head,
and having the mother place the infant skin to skin should increase the infant's
temperature. Nursing actions are needed first to correct the problem. If the problem
persists after interventions, notification may then be necessary. A slightly decreased
temperature can be treated in the mother's room. This would be an excellent time for
, parent teaching on prevention of cold stress. Mild temperature instability is an expected
deviation from normal during the first days as the infant adapts to external life.
11. 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 who 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. - ANSANS: D
An initial Apgar score of 10 is a good sign of healthy adaptation; however, it must be
repeated at the 5-minute mark.
12. With regard to umbilical cord care, nurses should be aware that:
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. - ANSANS: A
The cord stump is an excellent medium for bacterial growth. The nurse should first
check the clamp (or tie) and apply a second one. If the bleeding does not stop, the
nurse calls for assistance. The cord clamp is removed after 24 hours when it is dry. The
average cord separation time is 10 to 14 days.
13. 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). - ANSANS: C
The AGA range is large: between the 10th and the 90th percentiles for the infant's age.
The infant's length and size of the head are measured, but they do not affect the normal
weight designation. IUGR applies to the fetus, not the newborn's weight.
14. 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 the infant's 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. - ANSANS: B
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 is higher and sharper than the first.
