Chapter 24: Nursing Care of the Newborn and Family

Chapter 24: Nursing Care of the Newborn and Family

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

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?

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.

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?

ANS:  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?

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.

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?

ANS:  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?

ANS:  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