Chapter 23: Nursing Care of the Newborn and Family Perry: Maternal Child Nursing Care, 6th Edition

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. ANS: 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 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: 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. ANS: 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 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. 00:14 02:03 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: a. are benign if they disappear within 48 hours of birth. b. result from increased blood volume. c. should always be further investigated. d. usually occur with forceps delivery. ANS: 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. 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: a. apply an oil-based lotion to the newborn's skin to prevent dying and cracking. 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. ANS: 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. 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: a. the bleeding stops completely. b. yellow exudate forms over the glans. c. the PlastiBell rim falls off. d. the infant voids. ANS: D The infant should be observed for urination after the circumcision. Bleeding is a common complication after circumcision. The nurse will check the penis for 12 hours after a circumcision to assess and provide appropriate interventions for prevention and treatment of bleeding. Yellow exudates cover the glans penis in 24 hours after the circumcision. This is part of normal healing and not an infective process. The PlastiBell remains in place for about a week and falls off when healing has taken place. 6. A mother expresses fear about changing her infant's diaper after he is circumcised. What does the woman need to be taught to take care of the infant when she gets home? a. Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours. b. Apply constant, firm pressure by squeezing the penis with the fingers for at least 5 minutes if bleeding occurs. c. Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change. d. Wash off the yellow exudate that forms on the glans at least once every day to prevent infection. ANS: C Cleansing the penis gently with water and putting petroleum jelly around the glans after each diaper change are appropriate when caring for an infant who has had a circumcision. With each diaper change, the penis should be washed off with warm water to remove any urine or feces. If bleeding occurs, the nurse should apply gentle pressure to the site of the bleeding with a sterile gauze square. Yellow exudates cover the glans penis in 24 hours after the circumcision. This is part of normal healing and not an infective process. The exudates should not be removed. 7. When preparing to administer a hepatitis B vaccine to a newborn, the nurse should: a. obtain a syringe with a 25-gauge, 5/8-inch needle. b. confirm that the newborn's mother has been infected with the hepatitis B virus. c. assess the dorsogluteal muscle as the preferred site for injection. d. confirm that the newborn is at least 24 hours old. ANS: A The hepatitis B vaccine should be administered with a 25-gauge, 5/8-inch needle. Hepatitis B vaccination is recommended for all infants. If the infant is born to an infected mother who is a chronic carrier, hepatitis vaccine and hepatitis B immune globulin should be administered within 12 hours of birth. Hepatitis B vaccine should be given in the vastus lateralis muscle. Hepatitis B vaccine can be given at birth. 8. The nurse is performing a gestational age and physical assessment on the newborn. The infant appears to have an excessive amount of saliva. The nurse recognizes that this finding: a. is normal. b. indicates that the infant is hungry. c. may indicate that the infant has a tracheoesophageal fistula or esophageal atresia. d. may indicate that the infant has a diaphragmatic hernia. ANS: C The presence of excessive saliva in a neonate should alert the nurse to the possibility of tracheoesophageal fistula or esophageal atresia 9. As part of Standard Precautions, nurses wear gloves when handling the newborn. The chief reason is: a. to protect the baby from infection. b. that it is part of the Apgar protocol. c. to protect the nurse from contamination by the newborn. d. the nurse has primary responsibility for the baby during the first 2 hours. ANS: C Gloves are worn to protect the nurse from infection until the blood and amniotic fluid are cleaned off the newborn. 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. ANS: 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. ANS: 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. ANS: 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.