Chapter 24: Nursing Care of the Newborn and Family
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
ANS: 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 transition to
extrauterine life. An interval of every 15 minutes is too long to wait to complete this
assessment.
PTS: 1 DIF: Cognitive Level: Understand
TOP: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
2. A new father wants to know NUwRhaStI
mNedG atB
icT io.
nC asMput into his infant’s eyes and why it is
wO
needed. How does the nurse explain the purpose of the erythromycin ophthalmic ointment?
a. Erythromycin ophthalmic ointment destroys an infectious exudate caused by
Staphylococcus that could make the infant blind.
b. This ophthalmic ointment prevents gonorrheal infection of the infant’s eyes,
potentially acquired from the birth canal.
c. Erythromycin 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.
ANS: B
The nurse should explain that prophylactic erythromycin ophthalmic ointment is instilled in
the eyes of all neonates to prevent gonorrheal 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.
PTS: 1 DIF: Cognitive Level: Apply
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
ANS: 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.
PTS: 1 DIF: Cognitive Level: Analyzing
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.
ANS: C
Vitamin K is provided because the newborn does not have the intestinal flora to produce this
NUe RmSater
vitamin for the first week. Th INnal
GTdiet
B.hasOno 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.
PTS: 1 DIF: Cognitive Level: Understand
TOP: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
5. A newborn is jaundiced and is receiving phototherapy via ultraviolet bank lights. What is
the most appropriate nursing intervention when caring for an infant with hyperbilirubinemia
and receiving phototherapy?
a. Applying an oil-based lotion to the newborn’s skin to prevent dying and cracking
b. Limiting the newborn’s intake of milk to prevent nausea, vomiting, and diarrhea
c. Placing eye shields over the newborn’s closed eyes
d. Changing the newborn’s position every 4 hours
ANS: C
, The infant’s eyes must be protected by an opaque mask to prevent overexposure to the light.
Eye shields should completely cover the eyes but not occlude the nares. Lotions and
ointments should not be applied to the infant because they absorb heat and can cause burns.
The lights increase insensible water loss, placing the infant at risk for fluid loss and
dehydration. Therefore, adequate hydration is important for the infant. The infant should be
turned every 2 hours to expose all body surfaces to the light.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Planning
MSC: Client Needs: Safe and Effective Care Environment
6. Early this morning, an infant boy was circumcised using the PlastiBell method. Based on the
nurse’s evaluation, when will the infant be ready for discharge?
a. When the bleeding completely stops
b. When yellow exudate forms over the glans
c. When the PlastiBell plastic rim (bell) falls off
d. When the infant voids
ANS: D
The infant should be observed for urination after the circumcision. Bleeding is a common
complication after circumcision, and the nurse will check the penis for 12 hours after a
circumcision to assess and provide appropriate interventions for the prevention and
treatment of bleeding. Yellow exudate covers the glans penis in 24 hours after the
circumcision and is part of normal healing; yellow exudate is not an infective process. The
PlastiBell plastic rim (bell) remains in place for approximately a week and falls off when
healing has taken place.
NURSINGTB.COM
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
7. The nurse is preparing to administer a hepatitis B virus (HBV) vaccine to a newborn. Which
intervention by the nurse is correct?
a. Obtaining a syringe with a 25-gauge, 5/8-inch needle for medication
administration
b. Confirming that the newborn’s mother has been infected with the HBV
c. Assessing the dorsogluteal muscle as the preferred site for injection
d. Confirming that the newborn is at least 24 hours old
ANS: A
The HBV vaccine should be administered in the vastus lateralis muscle at childbirth with a
25-gauge, 5/8-inch needle and is recommended for all infants. If the infant is born to an
infected mother who is a chronic HBV carrier, then the hepatitis vaccine and HBV
immunoglobulin should be administered within 12 hours of childbirth.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
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
ANS: 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 transition to
extrauterine life. An interval of every 15 minutes is too long to wait to complete this
assessment.
PTS: 1 DIF: Cognitive Level: Understand
TOP: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
2. A new father wants to know NUwRhaStI
mNedG atB
icT io.
nC asMput into his infant’s eyes and why it is
wO
needed. How does the nurse explain the purpose of the erythromycin ophthalmic ointment?
a. Erythromycin ophthalmic ointment destroys an infectious exudate caused by
Staphylococcus that could make the infant blind.
b. This ophthalmic ointment prevents gonorrheal infection of the infant’s eyes,
potentially acquired from the birth canal.
c. Erythromycin 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.
ANS: B
The nurse should explain that prophylactic erythromycin ophthalmic ointment is instilled in
the eyes of all neonates to prevent gonorrheal 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.
PTS: 1 DIF: Cognitive Level: Apply
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
ANS: 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.
PTS: 1 DIF: Cognitive Level: Analyzing
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.
ANS: C
Vitamin K is provided because the newborn does not have the intestinal flora to produce this
NUe RmSater
vitamin for the first week. Th INnal
GTdiet
B.hasOno 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.
PTS: 1 DIF: Cognitive Level: Understand
TOP: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
5. A newborn is jaundiced and is receiving phototherapy via ultraviolet bank lights. What is
the most appropriate nursing intervention when caring for an infant with hyperbilirubinemia
and receiving phototherapy?
a. Applying an oil-based lotion to the newborn’s skin to prevent dying and cracking
b. Limiting the newborn’s intake of milk to prevent nausea, vomiting, and diarrhea
c. Placing eye shields over the newborn’s closed eyes
d. Changing the newborn’s position every 4 hours
ANS: C
, The infant’s eyes must be protected by an opaque mask to prevent overexposure to the light.
Eye shields should completely cover the eyes but not occlude the nares. Lotions and
ointments should not be applied to the infant because they absorb heat and can cause burns.
The lights increase insensible water loss, placing the infant at risk for fluid loss and
dehydration. Therefore, adequate hydration is important for the infant. The infant should be
turned every 2 hours to expose all body surfaces to the light.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Planning
MSC: Client Needs: Safe and Effective Care Environment
6. Early this morning, an infant boy was circumcised using the PlastiBell method. Based on the
nurse’s evaluation, when will the infant be ready for discharge?
a. When the bleeding completely stops
b. When yellow exudate forms over the glans
c. When the PlastiBell plastic rim (bell) falls off
d. When the infant voids
ANS: D
The infant should be observed for urination after the circumcision. Bleeding is a common
complication after circumcision, and the nurse will check the penis for 12 hours after a
circumcision to assess and provide appropriate interventions for the prevention and
treatment of bleeding. Yellow exudate covers the glans penis in 24 hours after the
circumcision and is part of normal healing; yellow exudate is not an infective process. The
PlastiBell plastic rim (bell) remains in place for approximately a week and falls off when
healing has taken place.
NURSINGTB.COM
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
7. The nurse is preparing to administer a hepatitis B virus (HBV) vaccine to a newborn. Which
intervention by the nurse is correct?
a. Obtaining a syringe with a 25-gauge, 5/8-inch needle for medication
administration
b. Confirming that the newborn’s mother has been infected with the HBV
c. Assessing the dorsogluteal muscle as the preferred site for injection
d. Confirming that the newborn is at least 24 hours old
ANS: A
The HBV vaccine should be administered in the vastus lateralis muscle at childbirth with a
25-gauge, 5/8-inch needle and is recommended for all infants. If the infant is born to an
infected mother who is a chronic HBV carrier, then the hepatitis vaccine and HBV
immunoglobulin should be administered within 12 hours of childbirth.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
