Chapter 22: The Normal Newborn: Nursing Care My Nursing Test Banks

Chapter 22: The Normal Newborn: Nursing Care

Test Bank

MULTIPLE CHOICE

1. A yellow crust has formed over the circumcision site. The mother calls the hotline at the local hospital, 5 days after her son was circumcised. She is very concerned. On which rationale should the nurse base her reply?

a.

After circumcision, the diaper should be changed frequently and fastened snugly.

b.

This yellow crust is an early sign of infection.

c.

The yellow crust should not be removed.

d.

Discontinue the use of petroleum jelly to the tip of the penis.

ANS: C

Feedback

A

The diaper should be fastened loosely to prevent rubbing or pressure on the incision site.

B

The normal yellowish exudate that forms over the site should be differentiated from the purulent drainage of infection.

C

Crust is a normal part of healing.

D

The only contraindication for petroleum jelly is the use of a PlastiBell.

PTS: 1 DIF: Cognitive Level: Application REF: p. 521

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

2. A new father wants to know what medication was put into his infants 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 infants eyes potentially acquired from the birth canal.

c.

Prevent potentially harmful exudate from invading the tear ducts of the infants eyes, leading to dry eyes.

d.

Prevent the infants 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.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 509

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

3. The normal term infant has little difficulty clearing its airway after birth. Most secretions are brought up to the oropharynx by the cough reflex. However, if the infant has excess secretions, the mouth and nasal passages can easily be cleared with a bulb syringe. When instructing parents on the correct use of this piece of equipment, it is important that the nurse teach them to

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

Feedback

A

The nasal passages should be suctioned one nostril at a time. The mouth should always be suctioned first.

B

After compression of the bulb it should be inserted into one side of the mouth. If it is inserted into the center of the mouth, the gag reflex is likely to be initiated.

C

The mouth should be suctioned first to prevent the infant from inhaling pharyngeal secretions by gasping as the nares are suctioned.

D

When the infants cry no longer sounds as though it is through mucus or a bubble, suctioning can be stopped. The bulb syringe should remain in the crib so that it is easily accessible if needed again.

PTS: 1 DIF: Cognitive Level: Application REF: p. 511

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

4. In providing and teaching cord care, what is an important principle?

a.

Cord care is done only to control bleeding.

b.

Alcohol is the only agent used for cord care.

c.

It takes a minimum of 24 days for the cord to separate.

d.

The process of keeping the cord dry will decrease bacterial growth.

ANS: D

Feedback

A

Cord care is to prevent infection and add in the drying of the cord.

B

No agents are necessary to facilitate drying of the cord.

C

The cord will fall off within 10 to 14 days.

D

Bacterial growth increases in a moist environment, so keeping the umbilical cord dry impedes bacterial growth.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 515

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

5. The nurses 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 infants head and have the mother perform kangaroo care.

c.

Tell the mother that the infant must be kept in the nursery and observed for the next 4 hours.

d.

Change the formula, as this is a sign of formula intolerance.

ANS: B

Feedback

A

Nursing actions are needed first to correct the problem. If the problem persists after interventions, notification may then be necessary.

B

A cap will prevent further heat loss from the head, and having the mother place the infant skin-to-skin should increase the infants temperature.

C

A slightly decreased temperature can be treated in the mothers room. This would be an excellent time for parent teaching on prevention of cold stress.

D

Mild temperature instability is an expected deviation from normal during the first days as the infant adapts to external life.

PTS: 1 DIF: Cognitive Level: Application REF: p. 512

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

6. When teaching parents about mandatory newborn screening, it is important for the nurse to explain that the main purpose is to

a.

Keep the state records updated.

b.

Allow accurate statistical information.

c.

Document the number of births.

d.

Recognize and treat newborn disorders early.

ANS: D

Feedback

A

This is not the main reason for the screening test.

B

This is not the main reason for the screening test.

C

The number of births does not come from the newborn screening test.

D

Early treatment of disorders will prevent morbidity associated with inborn errors of metabolism or other genetic conditions.

PTS: 1 DIF: Cognitive Level: Application REF: pp. 524-525

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

7. To prevent the kidnapping of newborns from the hospital, the nurse should

a.

Instruct the mother not to give her infant to anyone except the one nurse assigned to her that day.

b.

Question anyone who is seen walking in the hallways carrying an infant.

c.

Allow no visitors in the maternity area except those who have identification bracelets.

d.

Restrict the amount of time infants are out of the nursery.

ANS: B

Feedback

A

It is impossible for one nurse to be on call for one mother and baby for the entire shift, so the parents need to be able to identify the nurses who are working on the unit.

B

Infants should be transported in the hallways only in their cribs.

C

This will be difficult to monitor and will limit the mothers support system from visiting.

D

Infants need to spend time with the parents to facilitate the bonding process.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 517 | Box 22-1

OBJ: Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

8. The nurse administers vitamin K to the newborn for what reason?

a.

Most mothers have a diet deficient in vitamin K, which results in the infants being deficient.

b.

Vitamin K prevents the synthesis of prothrombin in the liver and must be given by injection.

c.

Bacteria that synthesize vitamin K are not present in the newborns intestinal tract.

d.

The supply of vitamin K is inadequate for at least 3 to 4 months, and the newborn must be supplemented.

ANS: C

Feedback

A

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.

B

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.

C

This is an accurate statement.

D

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: Comprehension REF: p. 509

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

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.

It is part of the Apgar protocol

c.

To protect the nurse from contamination by the newborn

d.

Because the nurse has primary responsibility for the baby during the first 2 hours

ANS: C

Feedback

A

Proper hand hygiene is all that is necessary to protect the infant from infection.

B

Wearing gloves is not necessary in order to complete the Apgar score assessment.

C

With the possibility of transmission of viruses such as HBV and HIV through maternal blood and amniotic fluid, the newborn must be considered a potential contamination source until proved otherwise. As part of Standard Precautions, nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing.

D

The nurse assigned to the mother-baby couplet has primary responsibility regardless of whether or not she wears gloves.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 509

OBJ: Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

10. With regard to lab tests and diagnostic tests in the hospital after birth, nurses should be aware that

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 done before the infant is 24 hours old, it should be repeated at age 1 to 2 weeks.

d.

Hearing screening is now mandated by federal law.

ANS: C

Feedback

A

States all test for PKU and hypothyroidism, but other genetic defects are not universally covered.

B

Federal law mandates newborn genetic screening; however, parents can decline testing. A waiver should be signed and a notation made in the infants medical record.

C

If testing is done prior to 24 hours of age, genetic screening should be repeated when the infant is 1 to 2 weeks old.

D

Federal law does not mandate screening for hearing problems; however, the majority of states have enacted legislation mandating newborn hearing screening. In the U.S. the majority (95%) of infants are screened for hearing loss prior to discharge from the hospital.

PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 525

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

11. Nurses can help parents deal with the issue and fact of circumcision if they explain

a.

The pros and cons of the procedure during the prenatal period

b.

That the American Academy of Pediatrics (AAP) recommends that all newborn males be routinely circumcised

c.

That circumcision is rarely painful and that any discomfort can be managed without medication

d.

That the infant will likely be alert and hungry shortly after the procedure

ANS: A

Feedback

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.

B

The AAP and other professional organizations note the benefits, but stop short of recommendation for routine circumcision.

C

Circumcision is painful and must be managed with environmental, nonpharmacologic, and pharmacologic measures.

D

Circumcision is painful and must be managed with environmental, nonpharmacologic, and pharmacologic measures.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 519

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

12. A nurse is responsible for teaching new parents about the hygienic care of their newborn. The nurse should tell the parents to

a.

Avoid washing the head for at least 1 week to prevent heat loss.

b.

Sponge bathe only until the cord has fallen off.

c.

Cleanse the ears and nose with cotton-tipped swabs, such as Q-tips.

d.

Water temperature should be at least 38 C.

ANS: D

Feedback

A

To prevent heat loss, the infants head should be bathed before unwrapping and undressing.

B

Tub baths may be initiated from birth. Ensure that the infant is fully immersed.

C

Q-tips should not be used, because 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.

D

The ideal temperature of the bath water should be at least 38 C or 100.4 F.

PTS: 1 DIF: Cognitive Level: Application REF: p. 515

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

13. An unfortunate but essential role of the nurse is protecting the infant from abduction. Which statement regarding the profile of a potential abductor is the most accurate?

a.

Male gender

b.

A young woman who has had a previous pregnancy loss

c.

A middle-aged woman past childbearing age

d.

A female with a number of children of her own

ANS: B

Feedback

A

Newborns are usually abducted by women who are familiar with the birth facility and its routines.

B

The woman is usually of childbearing age and may have had a previous pregnancy loss or has been unable to have a child of her own. She may want an infant to solidify the relationship with her husband or boyfriend and may have pretended to be pregnant.

C

Infant abductors are women of childbearing age, often overweight, who may live near the birth facility.

D

A woman who already has children of her own does not fit the profile of a potential abductor.

PTS: 1 DIF: Cognitive Level: Analysis REF: p. 517

OBJ: Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

14. When the nurse is in the process of health teaching it is very important that he or she consider the familys cultural beliefs regarding child care. One of these beliefs includes

a.

Arab women are anxious to breastfeed while still in the hospital.

b.

It is important to complement Asian parents about their new baby.

c.

Women from India tie a black thread around the infants waist.

d.

In the Korean culture the patients mother is the primary caregiver of the infant.

ANS: C

Feedback

A

Arab women are hesitant to breastfeed in the birth facility and wish to wait until they are home and their milk comes in.

B

Asian parents may be uneasy when caregivers are too complementary about the baby or casually touch the infants head.

C

Women from India may tie a black thread around the infants wrist, ankle, or waist to ward off evil spirits. This thread should not be removed by the nurse.

D

In the Korean culture, the husbands mother is the primary caregiver for the infant and the mother during the early weeks.

PTS: 1 DIF: Cognitive Level: Comprehension REF: pp. 523-524

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

15. 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 between 24 and 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.

ANS: A

Feedback

A

The home visit is ideally scheduled during the first 24 to 72 hours after discharge. This timing allows early assessment and intervention for problems with feedings, jaundice, newborn adaptation, and maternal-infant interaction.

B

Because home visits are expensive, they are not available in all geographic areas.

C

Visits are usually 60 to 90 minutes in length to allow enough time for assessment and teaching.

D

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: Application REF: p. 525

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

MULTIPLE RESPONSE

1. Pain should be assessed regularly in all newborn infants. If the infant is displaying physiologic or behavioral cures indicating pain, measures should be taken to manage the infants pain. Examples of nonpharmacologic pain management techniques include (select all that apply)

a.

Swaddling

b.

Nonnutritive sucking (pacifier)

c.

Skin-to-skin contact with the mother

d.

Sucrose

e.

Acetaminophen

ANS: A, B, C, D

Feedback

Correct

These interventions are all appropriate nonpharmacologic techniques used to manage pain in neonates. Other interventions include soothing music, dim lighting and speaking to the infant in a quiet voice.

Incorrect

Acetaminophen is a pharmacologic method of treating pain.

PTS: 1 DIF: Cognitive Level: Comprehension REF: pp. 519-520

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

2. As recently as 2005, the American Academy of Pediatrics revised safe sleep practices to assist in the prevention of sudden infant death syndrome. The nurse should model these practices in hospital and incorporate this information into the teaching for new parents. They include (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.

Placing the infants crib in the parents room

e.

A soft mattress

ANS: A, C, D

Feedback

Correct

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 babys head. The parents should be instructed to tuck any bedding securely around the mattress or use sleep sacks or bunting bags instead. Ideally the infants crib should be placed in the parents room.

Incorrect

The side-sleeping position is no longer an acceptable alternative according to the AAP. Infants should always sleep on a firm surface, ideally a firm crib mattress covered by a sheet only. Quilts, sheepskins, etc., should not be placed under the infant.

PTS: 1 DIF: Cognitive Level: Application REF: p. 516

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

3. Hearing loss occurs in 9% of newborns. Auditory screening of all newborns within the first month of life is recommended by the American Academy of Pediatrics. Reasons for having this testing performed include (select all that apply)

a.

To prevent or reduce developmental delay

b.

Reassurance for concerned new parents

c.

Early identification and treatment

d.

To help the child communicate better

e.

To achieve one of the Healthy People 2020 goals

ANS: A, C, D, E

Feedback

Correct

These are all appropriate reasons for auditory screening of the newborn. Infants who do not pass should be rescreened. If they still do not pass the test, they should have a full audiologic and medical evaluation by 3 months of age. If necessary, the infant should be enrolled in early intervention by 6 months of age.

Incorrect

New parents are often anxious regarding this test and the impending results; however, it is not the reason for the screening to be performed. Auditory screening is usually done before hospital discharge. It is important for the nurse to ensure that the infant receives the appropriate testing and that the test is fully explained to the parents. For infants that are referred for further testing and follow-up, it is important for the nurse to provide further explanation and emotional support.

PTS: 1 DIF: Cognitive Level: Application REF: p. 524

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

COMPLETION

1. The nurse is discussing infant care as part of the mother-infants couplet discharge planning. The mother asks the nurse When will my babys cord fall off? The nurse responds, Your babys cord should fall off by _______________ after birth.

ANS:

Two weeks

2 weeks

14 days

Cord separation is influenced by several factors, including type of cord care, type of birth and other perinatal events. The average cord separation time is 10 to 14 days. Some dried blood may be seen at the umbilicus after separation.

PTS: 1 DIF: Cognitive Level: Application REF: p. 515

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

TRUE/FALSE

1. Although circumcision continues to be a controversial procedure, many parents in the United States elect to have this surgery performed on their newborn sons. It is believed that newborns do not feel pain; therefore this is the optimum time for the procedure to be done and no anesthesia is required. Is this statement true or false?

ANS: F

At one time it was thought that newborns felt no pain. It is now known that pain stimuli pass along the fetal pain pathways as early as the second and third trimester. The nurse who assists with this procedure has a number of options available to reduce the pain response for the neonate. These include a dorsal penile block, EMLA, acetaminophen, and sucrose.

PTS: 1 DIF: Cognitive Level: Application REF: p. 519

OBJ: Nursing Process: Planning and Implementation

MSC: Client Needs: Physiologic Integrity

2. An important nursing intervention is maintaining safe glucose levels in the newborn. A common practice is to feed infants either breast milk or formula if glucose screening shows results of 40 to 45 mg/dL or less. Is this statement true or false?

ANS: T

Glucose water alone is not recommended for newborns because the rapid rise in glucose, will result in increased in sling production, causing a further drop in the blood glucose level. Milk provides a longer-lasting supply of glucose for the newborn.

PTS: 1 DIF: Cognitive Level: Application REF: p. 514

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

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