Maternal Newborn Child Nursing Care: Concepts and Practice Questions
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. - ansANS: 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
1. Pain should be assessed regularly in all newborn infants. If the infant is displaying physiologic or behavioral
cues indicating pain, measures should be taken to manage the pain. Examples of nonpharmacologic pain
management techniques include: (Select all that apply.)
a. swaddling.
b. nonnutritive sucking.
c. skin-to-skin contact with the mother.
d. sucrose.
e. acetaminophen. - ansANS: 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.
10. The nurse's 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 infant's head.
c. tell the mother that the infant must be kept in the nursery and observed for the next 4 hours.
d. change the formula because this is a sign of formula intolerance. - ansANS: B
Keeping the head well covered with a cap will prevent further heat loss from the head, and having the mother
place the infant skin to skin should increase the infant's temperature. Nursing actions are needed first to
correct the problem. If the problem persists after interventions, notification may then be necessary. A slightly
, decreased temperature can be treated in the mother's room. This would be an excellent time for parent
teaching on prevention of cold stress. Mild temperature instability is an expected deviation from normal during
the first days as the infant adapts to external life.
11. An Apgar score of 10 at 1 minute after birth would indicate a(n):
a. infant having no difficulty adjusting to extrauterine life and needing no further testing.
b. infant in severe distress who needs resuscitation.
c. prediction of a future free of neurologic problems.
d. infant having no difficulty adjusting to extrauterine life but who should be assessed again at 5 minutes after
birth. - ansANS: D
An initial Apgar score of 10 is a good sign of healthy adaptation; however, it must be repeated at the 5-minute
mark.
12. With regard to umbilical cord care, nurses should be aware that:
a. the stump can easily become infected.
b. a nurse noting bleeding from the vessels of the cord 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. - ansANS: 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 the bleeding does not stop, the nurse calls for assistance. The cord clamp is removed
after 24 hours when it is dry. The average cord separation time is 10 to 14 days.
13. In the classification of newborns by gestational age and birth weight, the appropriate for gestational age
(AGA) weight would:
a. fall between the 25th and 75th percentiles for the infant's age.
b. depend on the infant's length and the size of the head.
c. fall between the 10th and 90th percentiles for the infant's age.
d. be modified to consider intrauterine growth restriction (IUGR). - ansANS: C
The AGA range is large: between the 10th and the 90th percentiles for the infant's age. The infant's length and
size of the head are measured, but they do not affect the normal weight designation. IUGR applies to the fetus,
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. - ansANS: 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
1. Pain should be assessed regularly in all newborn infants. If the infant is displaying physiologic or behavioral
cues indicating pain, measures should be taken to manage the pain. Examples of nonpharmacologic pain
management techniques include: (Select all that apply.)
a. swaddling.
b. nonnutritive sucking.
c. skin-to-skin contact with the mother.
d. sucrose.
e. acetaminophen. - ansANS: 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.
10. The nurse's 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 infant's head.
c. tell the mother that the infant must be kept in the nursery and observed for the next 4 hours.
d. change the formula because this is a sign of formula intolerance. - ansANS: B
Keeping the head well covered with a cap will prevent further heat loss from the head, and having the mother
place the infant skin to skin should increase the infant's temperature. Nursing actions are needed first to
correct the problem. If the problem persists after interventions, notification may then be necessary. A slightly
, decreased temperature can be treated in the mother's room. This would be an excellent time for parent
teaching on prevention of cold stress. Mild temperature instability is an expected deviation from normal during
the first days as the infant adapts to external life.
11. An Apgar score of 10 at 1 minute after birth would indicate a(n):
a. infant having no difficulty adjusting to extrauterine life and needing no further testing.
b. infant in severe distress who needs resuscitation.
c. prediction of a future free of neurologic problems.
d. infant having no difficulty adjusting to extrauterine life but who should be assessed again at 5 minutes after
birth. - ansANS: D
An initial Apgar score of 10 is a good sign of healthy adaptation; however, it must be repeated at the 5-minute
mark.
12. With regard to umbilical cord care, nurses should be aware that:
a. the stump can easily become infected.
b. a nurse noting bleeding from the vessels of the cord 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. - ansANS: 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 the bleeding does not stop, the nurse calls for assistance. The cord clamp is removed
after 24 hours when it is dry. The average cord separation time is 10 to 14 days.
13. In the classification of newborns by gestational age and birth weight, the appropriate for gestational age
(AGA) weight would:
a. fall between the 25th and 75th percentiles for the infant's age.
b. depend on the infant's length and the size of the head.
c. fall between the 10th and 90th percentiles for the infant's age.
d. be modified to consider intrauterine growth restriction (IUGR). - ansANS: C
The AGA range is large: between the 10th and the 90th percentiles for the infant's age. The infant's length and
size of the head are measured, but they do not affect the normal weight designation. IUGR applies to the fetus,
