Chapter 17: Assessment and Care of the Newborn and Family

Chapter 17: Assessment and Care of the Newborn and Family

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

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.

 

ANS: C

 

	Feedback
A	The Apgar score is performed at 1 minute and 5 minutes after birth.
B	The Apgar score is performed at 1 minute and 5 minutes after birth.
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.
D	The Apgar score is performed at 1 minute and 5 minutes after birth.

 

DIF:   Cognitive Level: Comprehension  REF:  480

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Assessment

 

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 Ilotycin 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

 

	Feedback
A	Prophylactic ophthalmic ointment is instilled in the eyes of all neonates to prevent gonorrheal or chlamydial infection.
B	This is an accurate explanation.
C	Prophylactic ophthalmic ointment is not instilled to prevent dry eyes. It is instilled to prevent gonorrheal or chlamydial infection.
D	Prophylactic ophthalmic ointment has no bearing on vision other than to protect against infection that may lead to vision problems.

 

DIF:   Cognitive Level: Comprehension  REF:  484

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Planning

 

3. The nurse is using the 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

 

ANS: A

 

	Feedback
A	Term infants typically have a flexed posture.
B	Abundant lanugo usually is seen on preterm infants.
C	Smooth, pink skin with visible veins is seen on preterm infants.
D	Faint red marks usually are seen on preterm infants.

 

DIF:   Cognitive Level: Comprehension  REF:  487

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Diagnosis

 

4. 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

 

	Feedback
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.
B	Petechiae may result from decreased platelet formation.
C	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.
D	Petechiae usually occur with a breech presentation vaginal birth.

 

DIF:   Cognitive Level: Application        REF:  490

OBJ:  Client Needs: Health Promotion and Maintenance        TOP:  Nursing Process: Assessment