Maternity and Women's Health Care 12th Edition Lowdermilk Test Bank
Chapter 24: Nursing Care of the Newborn and Family
Lowdermilk: Maternity & Women’s Health Care, 12th Edition
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
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RSI
2. A new father wants to know
what
medication
NGTB.Cwas
OMput into his infant’s eyes and why it is
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?
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a.
b.
c.
d.
Blood glucose of 45 mg/dl using a Dextrostix screening method
Heart rate of 160 beats per minute after vigorously crying
Laceration of the cheek
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
NURmaternal
B.C
M
SINGTdiet
vitamin for the first week. The
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
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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.
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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
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8. The nurse is performing a gestational age and physical assessment on the newborn. The
infant appears to have an excessive amount of saliva. This clinical finding may be indicative
of what?
a. Excessive saliva is a normal finding in the newborn.
b. Excessive saliva in a neonate indicates that the infant is hungry.
c. It may indicate that the infant has a tracheoesophageal fistula or esophageal atresia.
d. Excessive saliva 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 a
tracheoesophageal fistula or esophageal atresia. Excessive salivation may not be a normal
finding and should be further assessed for the possibility that the infant has an esophageal
abnormality. The hungry infant reacts by making sucking motions, rooting, or making
hand-to-mouth movements. The infant with a diaphragmatic hernia exhibits severe
respiratory distress.
PTS: 1
DIF: Cognitive Level: Analyze
TOP: Nursing Process: Assessment
MSC: Client Needs: Physiologic Integrity
9. At 1 minute after birth a nurse assesses an infant and notes a heart rate of 80 beats per
minute, some flexion of extremities, a weak cry, grimacing, and a pink body but blue
extremities. Which Apgar score does the nurse calculate based upon these observations and
signs?
a. 4
b. 5
c. 6
d. 7
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ANS: B
Each of the five signs the nurse notes scores a 1 on the Apgar scale, for a total of 5. A score
of 4 is too low for this infant. A score of 6 is too high for this infant. A score of 7 is too high
for an infant with this presentation.
PTS: 1
DIF: Cognitive Level: Apply
TOP: Nursing Process: Assessment
MSC: Client Needs: Physiologic Integrity
10. Which statement accurately describes an appropriate-for-gestational age (AGA) weight
assessment?
a. AGA weight assessment falls between the 25th and 75th percentiles for the
infant’s age.
b. AGA weight assessment depends on the infant’s length and the size of the
newborn’s head.
c. AGA weight assessment falls between the 10th and 90th percentiles for the
infant’s age.
d. AGA weight assessment is modified to consider intrauterine growth restriction
(IUGR).
ANS: C
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Maternity and Women's Health Care 12th Edition Lowdermilk Test Bank
An AGA weight falls between the 10th and 90th percentiles for the infant’s age. The AGA
range is larger than the 25th and 75th percentiles. The infant’s length and head size are
measured, but these measurements do not affect the normal weight designation. IUGR
applies to the fetus, not to the newborn’s weight.
PTS: 1
DIF: Cognitive Level: Understand
TOP: Nursing Process: Diagnosis
MSC: Client Needs: Health Promotion and Maintenance
11. The nurse is completing a physical examination of the newborn 24 hours after birth. Which
component of the evaluation is correct?
a. The parents are excused to reduce their normal anxiety.
b. The nurse can gauge the neonate’s maturity level by assessing his or her general
appearance.
c. Once often neglected, blood pressure is now routinely checked.
d. When the nurse listens to the neonate’s heart, the S1 and S2 sounds can be heard;
the S1 sound is somewhat higher in pitch and sharper than the S2 sound.
ANS: B
The nurse is looking at skin color, alertness, cry, head size, and other features. The parents’
presence actively involves them in child care and gives the nurse the chance to observe their
interactions. Blood pressure is not usually taken unless cardiac problems are suspected. The
S2 sound is higher and sharper than the S1 sound.
PTS: 1
DIF: Cognitive Level: Apply
TOP: Nursing Process: Assessment
MSC: Client Needs: Health
Maintenance
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OM
12. The most serious complication of an infant heelstick is necrotizing osteochondritis resulting
from lancet penetration of the bone. What approach should the nurse take when performing
the test to prevent this complication?
a. Lancet should penetrate at the outer aspect of the heel.
b. Lancet should penetrate the walking surface of the heel.
c. Lancet should penetrate the ball of the foot.
d. Lancet should penetrate the area just below the fifth toe.
ANS: A
The stick should be made at the outer aspect of the heel and should penetrate no deeper than
2.4 mm. Repeated trauma to the walking surface of the heel can cause fibrosis and scarring
that can lead to problems with walking later in life. The ball of the foot and the area below
the fifth toe are inappropriate sites for a heelstick.
PTS: 1
DIF: Cognitive Level: Apply
TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
13. If the newborn has excess secretions, the mouth and nasal passages can be easily cleared
with a bulb syringe. How should the nurse instruct the parents on the use of this instrument?
a. Avoid suctioning the nares.
b. Insert the compressed bulb into the center of the mouth.
c. Suction the mouth first.
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d. Remove the bulb syringe from the crib when finished.
ANS: C
The mouth should always be suctioned first to prevent the infant from inhaling pharyngeal
secretions by gasping as the nares are suctioned. After compressing the bulb, the syringe
should be inserted into one side of the mouth. If it is inserted into the center of the mouth,
then the gag reflex is likely to be initiated. When the infant’s cry no longer sounds as though
it is through mucus or a bubble, suctioning can be stopped. The nasal passages should be
suctioned one nostril at a time. The bulb syringe should remain in the crib so that it is easily
accessible if needed again.
PTS: 1
DIF: Cognitive Level: Apply
TOP: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
14. As part of the infant discharge instructions, the nurse is reviewing the use of the infant car
safety seat. Which information is the highest priority for the nurse to share?
a. Infant carriers are okay to use until an infant car safety seat can be purchased.
b. For traveling on airplanes, buses, and trains, infant carriers are satisfactory.
c. Infant car safety seats are used for infants only from birth to 15 pounds.
d. Infant car seats should be rear facing and placed in the back seat of the car.
ANS: D
An infant placed in the front seat could be severely injured by an air bag that deploys during
an automobile accident. Infants should travel only in federally approved, rear-facing safety
seats secured in the rear seat and only in federally approved safety seats even when traveling
on a commercial vehicle. Infants should use a rear-facing car seat from birth to 20 pounds
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and to age 1 year.
PTS: 1
DIF: Cognitive Level: Apply
TOP: Nursing Process: Planning
MSC: Client Needs: Safe and Effective Care Environment
15. A nurse is responsible for teaching new parents regarding the hygienic care of their
newborn. Which instruction should the nurse provide regarding bathing?
a. Avoid washing the head for at least 1 week to prevent heat loss.
b. Sponge bathe the newborn for the first month of life.
c. Cleanse the ears and nose with cotton-tipped swabs, such as Q-tips.
d. Create a draft-free environment of at least 26° C (75° F) when bathing the infant.
ANS: D
The temperature of the room should be least 26° C (75° F), and the bathing area should be
free of drafts. To prevent heat loss, the infant’s head should be bathed before unwrapping
and undressing. Tub baths may be initiated from birth. Ensure that the infant is fully
immersed. Q-tips should not be used; they may cause injury. A corner of a moistened
washcloth should be twisted into shape so that it can be used to cleanse the ears and nose.
PTS: 1
DIF: Cognitive Level: Apply
TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
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16. A 3.8-kg infant was vaginally delivered at 39 weeks of gestation after a 30-minute second
stage. A nuchal cord occurred. After the birth, the infant is noted to have petechiae over the
face and upper back. Based on the nurse’s knowledge, which information regarding
petechiae should be shared with the parents?
a. Petechiae are benign if they disappear within 48 hours of childbirth.
b. These hemorrhagic areas may result from increased blood volume.
c. Petechiae should always be further investigated.
d. Petechiae usually occur with a forceps delivery.
ANS: A
Petechiae that are acquired during birth may extend over the upper portion of the trunk and
face. These lesions are benign if they disappear within 2 or 3 days of birth and no new
lesions appear. Petechiae may result from decreased platelet formation. In this infant, the
presence of petechiae is more likely a soft-tissue injury resulting from the nuchal cord at
birth. Unless the lesions do not dissipate in 2 days, no reason exists to alarm the family.
Petechiae usually occur with a breech presentation vaginal birth.
PTS: 1
DIF: Cognitive Level: Apply
TOP: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
17. What is the nurse’s initial action while caring for an infant with a slightly decreased
temperature?
a. Immediately notify the physician.
b. Place a cap on the infant’s head, and have the mother perform kangaroo care.
c. Tell the mother that theNinfant
must
kept O
inMthe nursery and observed for the
URSI
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next 4 hours.
d. Change the formula; a decreased body temperature is a sign of formula intolerance.
ANS: B
Keeping the head well covered with a cap prevents further heat loss from the head and
placing the infant skin-to-skin against the mother should increase the infant’s temperature.
Nursing actions are needed first to correct the problem. If the problem persists after the
interventions, physician notification may then be necessary. A slightly decreased
temperature can be treated in the mother’s room, offering an excellent time for parent
teaching on the prevention of cold stress. Mild temperature instability is an expected
deviation from normal during the first days after childbirth as the infant adapts to external
life.
PTS: 1
DIF: Cognitive Level: Apply
TOP: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
18. How should the nurse interpret an Apgar score of 10 at 1 minute after birth?
a. The infant is having no difficulty adjusting to extrauterine life and needs no further
testing.
b. The infant is in severe distress and needs resuscitation.
c. The nurse predicts a future free of neurologic problems.
d. The infant is having no difficulty adjusting to extrauterine life but should be
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assessed again at 5 minutes after birth.
ANS: D
An initial Apgar score of 10 is a good sign of healthy adaptation; however, the test must be
repeated at the 5-minute mark.
PTS: 1
DIF: Cognitive Level: Understand
TOP: Nursing Process: Planning
MSC: Client Needs: Physiologic Integrity
19. The nurse should be cognizant of which important statement regarding care of the umbilical
cord?
a. The stump can become easily infected.
b. If bleeding occurs from the vessels of the cord, then the nurse 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 bleeding occurs and does not stop, then the
nurse should call for assistance. The cord clamp is removed after 24 hours when it is dry.
The average cord separation time is 10 to 14 days.
PTS: 1
DIF: Cognitive Level: Understand
TOP: Nursing Process: Planning
MSC: Client Needs: Safe and Effective Care Environment
N R I G B.C M
U Sat N
T
O should educate parents regarding safe
20. As part of their teaching function
discharge,
nurses
sleep. Based on the most recent evidence, which information is incorrect and should be
discussed with parents?
a. Prevent exposure to people with upper respiratory tract infections.
b. Keep the infant away from secondhand smoke.
c. Avoid loose bedding, water beds, and beanbag chairs.
d. Place the infant on his or her abdomen to sleep.
ANS: D
The infant should be laid down to sleep on his or her back for better breathing and to
prevent sudden infant death syndrome (SIDS). Grandmothers may encourage the new
parents to place the infant on the abdomen; however, evidence shows “back to sleep”
reduces SIDS. Infants are vulnerable to respiratory infections; therefore, infected people
must be kept away. Secondhand smoke can damage lungs. Infants can suffocate in loose
bedding and in furniture that can trap them. Per AAP guidelines, infants should always be
placed “back to sleep” and allowed tummy time to play to prevent plagiocephaly.
PTS: 1
DIF: Cognitive Level: Apply
TOP: Nursing Process: Planning
MSC: Client Needs: Safe and Effective Care Environment
21. Which intervention by the nurse would reduce the risk of abduction of the newborn from the
hospital?
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a. Instructing the mother not to give her infant to anyone except the one nurse
assigned to her that day
b. Applying an electronic and identification bracelet to the mother and the infant
c. Carrying the infant when transporting him or her in the halls
d. Restricting the amount of time infants are out of the nursery
ANS: B
A measure taken by many facilities is to band both the mother and the baby with matching
identification bracelets and band the infant with an electronic device that will sound an
alarm if the infant is removed from the maternity unit. It is impossible for one nurse to be on
call for one mother and baby for the entire shift; therefore, parents need to be able to
identify the nurses who are working on the unit. Infants should always be transported in
their bassinette for both safety and security reasons. All maternity unit nursing staff should
have unique identification bracelets in comparison with the rest of the hospital. Infants
should remain with their parents and spend as little time in the nursery as possible.
PTS: 1
DIF: Cognitive Level: Apply
TOP: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
22. Nursing follow-up care often includes home visits for the new mother and her infant. Which
information related to home visits is correct?
a. Ideally, the visit is scheduled within 72 hours after discharge.
b. Home visits are available in all areas.
c. Visits are completed within a 30-minute time frame.
d. Blood draws are not a part of the home visit.
N R I G B.C M
U S N T
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ANS: A
The home visit is ideally scheduled within 72 hours after discharge. This timing allows early
assessment and intervention for problems with feedings, jaundice, newborn adaptation, and
maternal-infant interaction. Because of geographic distances, home visits are not available
in all locales. Visits are usually 60 to 90 minutes in length to allow enough time for
assessment and teaching. When jaundice is found, the nurse can discuss the implications and
check the transcutaneous bilirubin level or draw blood for testing.
PTS: 1
DIF: Cognitive Level: Apply
TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
23. Screening for critical congenital heart disease (CCHD) was added to the uniform screening
panel in 2011. The nurse has explained this testing to the new mother. Which action by the
nurse related to this test is correct?
a. Screening is performed when the infant is 12 hours of age.
b. Testing is performed with an electrocardiogram.
c. Oxygen (O2) is measured in both hands and in the right foot.
d. A passing result is an O2 saturation of 95%.
ANS: D
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Screening is performed when the infant is between 24 and 48 hours of age. The test is
performed using pulse oximetry technology. O2 is measured in the right hand and one foot.
A passing result is an O2 saturation of 95% with a 3% absolute difference between upper
and lower extremity readings.
PTS: 1
DIF: Cognitive Level: Applying
TOP: Nursing Process: Assessment
MSC: Client Needs: Physiologic Integrity
MULTIPLE RESPONSE
1. Pain should be regularly assessed in all newborns. If the infant is displaying physiologic or
behavioral cues that indicate pain, then measures should be taken to manage the pain. Which
interventions are examples of nonpharmacologic pain management techniques? (Select all
that apply.)
a. Swaddling
b. Nonnutritive sucking
c. Skin-to-skin contact with the mother
d. Sucrose
e. Acetaminophen
ANS: 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.
PTS: 1
DIF: Cognitive Level: Understand
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OM Client Needs: Physiologic Integrity
TOP: Nursing Process: Implementation
MSC:
2. Which practices are ideal for role modeling when attempting to prevent sudden infant death
syndrome (SIDS)? (Select all that apply.)
a. Fully supine position for all sleep
b. Side-sleeping position as an acceptable alternative
c. “Tummy time” for play
d. Infant sleep sacks or buntings
e. Soft mattress
ANS: A, C, D
The “back to sleep” position is now recommended as the only position for every sleep
period. To prevent positional plagiocephaly (flattening of the head) the infant should spend
time on his or her abdomen while awake and for play. Loose sheets and blankets may be
dangerous because they could easily cover the baby’s head. The parents should be instructed
to tuck any bedding securely around the mattress or use sleep sacks or bunting bags instead.
The side-sleeping position is no longer an acceptable alternative position, according to the
AAP. Infants should always sleep on a firm surface, ideally a firm crib mattress covered by
a sheet only. Quilts and sheepskins, among other bedding, should not be placed under the
infant.
PTS: 1
DIF: Cognitive Level: Apply
TOP: Nursing Process: Implementation
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MSC: Client Needs: Health Promotion and Maintenance
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