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.
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?
a. Erythromycin (Ilotycin) ophthalmic ointment destroys an infectious exudate caused byStaphylococcus that could make the infant blind.
b. This ophthalmic ointment prevents gonorrheal and chlamydial infection of the infant’s eyes, potentially acquired from the birth canal.
c. Erythromycin (Ilotycin) 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 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?
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
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?
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.
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?
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
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
6. 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. DIF: Cognitive Level: Apply REF: p. 572 TOP: Nursing Process: Planning
MSC: Client Needs: Safe and Effective Care Environment
7. 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
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.
DIF: Cognitive Level: Apply REF: p. 582 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance
8. 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
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. DIF: Cognitive Level: Apply REF: p. 579
TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 9. 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.
DIF: Cognitive Level: Analyze REF: p. 561
10. A mother is changing the diaper of her newborn son and notices that his scrotum appears large and swollen. The client is concerned. What is the best response from the nurse?
a. “A large scrotum and swelling indicate a hydrocele, which is a common finding in male newborns.”
b. “I don’t know, but I’m sure it is nothing.”
c. “Your baby might have testicular cancer.”
d. “Your baby’s urine is backing up into his scrotum.”
ANS: A
Explaining what a hydrocele is and its characteristics is the most appropriate response by the nurse. The swelling usually decreases without intervention. Telling the mother that the condition is nothing important is inappropriate and does not address the mother’s concern. Furthermore, if the nurse is unaware of any abnormal-appearing condition, then she should seek assistance from additional resources. Telling the mother that her newborn might have testicular cancer is inaccurate, inappropriate, and could cause the new mother undue worry. Urine will not back up into the scrotum if the infant has a hydrocele. Any nurse caring for the normal newborn should
understand basic anatomy.
DIF: Cognitive Level: Apply REF: p. 563 TOP: Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance
11. What is the primary rationale for nurses wearing gloves when handling the newborn?
b. As part of the Apgar protocol
c. To protect the nurse from contamination by the newborn
d. Because the nurse has the primary responsibility for the baby during the first 2 hours
ANS: C
With the possibility of transmission of viruses such as HBV and the human immunodeficiency virus (HIV) through maternal blood and amniotic fluid, the
newborn must be considered a potential contamination source until proven otherwise. As part of Standard Precautions, nurses should wear gloves when handling the
newborn until blood and amniotic fluid are removed by bathing. Proper hand hygiene is all that is necessary to protect the infant from infection. Wearing gloves is not necessary to complete the Apgar score assessment. The nurse assigned to the mother- baby couplet has primary responsibility for the newborn, regardless of whether or not she wears gloves.
DIF: Cognitive Level: Understand REF: p. 549 TOP: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
12. 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
c. 6
d. 7
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.
DIF: Cognitive Level: Apply REF: p. 551
TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
13. 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).
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. DIF: Cognitive Level: Understand REF: p. 553 TOP: Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance
14. 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 S1sound 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.
DIF: Cognitive Level: Apply REF: p. 551
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 15. The nurse is teaching new parents about metabolic screening for the newborn. Which statement is most helpful to these clients?
a. All states test for phenylketonuria (PKU), hypothyroidism, cystic fibrosis, and sickle cell diseases.
b. Federal law prohibits newborn genetic testing without parental consent.
c. If genetic screening is performed before the infant is 24 hours old, then it should be repeated at age 1 to 2 weeks.
d. Hearing screening is now mandated by federal law.
ANS: C
If testing is performed before the infant is 24 hours old, then genetic screening should be repeated when the infant is 1 to 2 weeks old. All states test for PKU and
hypothyroidism but not for other genetic defects. Federal law mandates newborn genetic screening; however, parents can decline the testing. A waiver should be signed, and a notation made in the infant’s medical record. Federal law does not mandate screening for hearing problems; however, the majority of states have enacted legislation mandating newborn hearing screening. In the United States, the majority (95%) of infants are screened for hearing loss before discharge from the hospital. DIF: Cognitive Level: Apply REF: p. 575 TOP: Nursing Process: Planning
MSC: Client Needs: Physiologic Integrity
16. Which explanation will assist the parents in their decision on whether they should circumcise their son?
a. The circumcision procedure has pros and cons during the prenatal period.
newborns be routinely circumcised.
c. Circumcision is rarely painful, and any discomfort can be managed without medication.
d. The infant will likely be alert and hungry shortly after the procedure.
ANS: A
Parents need to make an informed choice regarding newborn circumcision, based on the most current evidence and recommendations. Health care providers and nurses who care for childbearing families should provide factual, unbiased information regarding circumcision and give parents opportunities to discuss the risks and benefits of the procedure. The AAP and other professional organizations note the benefits but stop short of recommending routine circumcision. Circumcision is painful and must be managed with environmental, nonpharmacologic, and pharmacologic measures. After the procedure, the infant may be fussy for several hours, or he may be sleepy and difficult to awaken for feeding.
DIF: Cognitive Level: Understand REF: p. 580 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance
17. 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.
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.
DIF: Cognitive Level: Apply REF: p. 576
TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
18. 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.
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. DIF: Cognitive Level: Apply REF: p. 567
TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 19. 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 and to age 1 year.
DIF: Cognitive Level: Apply REF: p. 589 TOP: Nursing Process: Planning MSC: Client Needs: Safe and Effective Care Environment
20. 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 24° C (75° F) when bathing the infant.
ANS: D
The temperature of the room should be 24° C (75° F), and the bathing area should be free of drafts. To prevent heat loss, the infant’s head should be bathed before