Chapter 26: Nursing Care of the Newborn and Family
MULTIPLE CHOICE
1. An infant boy was born just a few minutes ago and the nurse is assessing the Apgar score.
When is the Apgar score performed?
a. It is performed only if the newborn is in
obvious distress.
b. It is performed once by the obstetrician,
just after the birth.
c. It is performed at least twice, 1 minute and
5 minutes after birth.
d. It is performed every 15 minutes
during the newborn’s first hour after
birth.
ANS: 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.
DIF: Cognitive Level: Comprehension REF: p. 673 OBJ: Nursing
Process: Assessment
2. A new father wants to know what medication was put into his infant’s eyes and why it is
needed. What does the nurse explain to the father about the purpose of the erythromycin
ophthalmic ointment?
a. It destroys an infectious exudate caused by
Staphylococcusthat could make the infant
blind.
b. It prevents gonorrheal and chlamydial
infection of the infant’s eyes that is
potentially acquired from the birth canal.
c. It prevents potentially harmful exudate
from invading the tear ducts of the infant’s
eyes, leading to dry eyes.
d. It prevents the infant’s eyelids from
sticking together and helps the infant
see.
ANS: B
The purpose of the erythromycin ophthalmic ointment is to prevent gonorrheal and chlamydial
infection of the infant’s eyes that is potentially acquired from the birth canal. Prophylactic
, ophthalmic ointment is instilled in the eyes of all neonates to prevent gonorrheal or chlamydial
infection. Prophylactic ophthalmic ointment is not instilled to prevent dry eyes. Prophylactic
ophthalmic ointment has no bearing on vision other than to protect against infection that may
lead to vision problems.
DIF: Cognitive Level: ComprehensionREF: p. 676 |Medication Guide OBJ:
Nursing Process: Planning
3. The nurse is using the Ballard scale to determine the gestational age of a newborn. Which 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 usually is seen on preterm
infants. Smooth, pink skin with visible veins is seen on preterm infants. Faint red marks usually
are seen on preterm infants.
DIF: Cognitive Level: ComprehensionREF: p. 690 | Figure 26-4 OBJ:
Nursing Process: Diagnosis
4. A 3800 g infant was delivered vaginally at 39 weeks after a 30-minute second stage. There was
a nuchal cord. After birth, the infant had petechiae over the face and upper back. Which
information would be accurate to be given to the infant’s parents about petechiae?
a.
48 hours of birth.
b. They result from increased blood volume.
c. They should always be further
investigated.
d. They usually occur with forceps
delivery.
ANS: A They
are benign if they disappear within
Petechiae, or pinpoint hemorrhagic areas, acquired during birth may extend over the upper
portion of the trunk and face. These lesions are benign if they disappear within 2 days of birth
and no new lesions appear. Petechiae may result from decreased platelet formation. In this
situation, the presence of petechiae is most likely a soft-tissue injury resulting from the nuchal
MULTIPLE CHOICE
1. An infant boy was born just a few minutes ago and the nurse is assessing the Apgar score.
When is the Apgar score performed?
a. It is performed only if the newborn is in
obvious distress.
b. It is performed once by the obstetrician,
just after the birth.
c. It is performed at least twice, 1 minute and
5 minutes after birth.
d. It is performed every 15 minutes
during the newborn’s first hour after
birth.
ANS: 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.
DIF: Cognitive Level: Comprehension REF: p. 673 OBJ: Nursing
Process: Assessment
2. A new father wants to know what medication was put into his infant’s eyes and why it is
needed. What does the nurse explain to the father about the purpose of the erythromycin
ophthalmic ointment?
a. It destroys an infectious exudate caused by
Staphylococcusthat could make the infant
blind.
b. It prevents gonorrheal and chlamydial
infection of the infant’s eyes that is
potentially acquired from the birth canal.
c. It prevents potentially harmful exudate
from invading the tear ducts of the infant’s
eyes, leading to dry eyes.
d. It prevents the infant’s eyelids from
sticking together and helps the infant
see.
ANS: B
The purpose of the erythromycin ophthalmic ointment is to prevent gonorrheal and chlamydial
infection of the infant’s eyes that is potentially acquired from the birth canal. Prophylactic
, ophthalmic ointment is instilled in the eyes of all neonates to prevent gonorrheal or chlamydial
infection. Prophylactic ophthalmic ointment is not instilled to prevent dry eyes. Prophylactic
ophthalmic ointment has no bearing on vision other than to protect against infection that may
lead to vision problems.
DIF: Cognitive Level: ComprehensionREF: p. 676 |Medication Guide OBJ:
Nursing Process: Planning
3. The nurse is using the Ballard scale to determine the gestational age of a newborn. Which 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 usually is seen on preterm
infants. Smooth, pink skin with visible veins is seen on preterm infants. Faint red marks usually
are seen on preterm infants.
DIF: Cognitive Level: ComprehensionREF: p. 690 | Figure 26-4 OBJ:
Nursing Process: Diagnosis
4. A 3800 g infant was delivered vaginally at 39 weeks after a 30-minute second stage. There was
a nuchal cord. After birth, the infant had petechiae over the face and upper back. Which
information would be accurate to be given to the infant’s parents about petechiae?
a.
48 hours of birth.
b. They result from increased blood volume.
c. They should always be further
investigated.
d. They usually occur with forceps
delivery.
ANS: A They
are benign if they disappear within
Petechiae, or pinpoint hemorrhagic areas, acquired during birth may extend over the upper
portion of the trunk and face. These lesions are benign if they disappear within 2 days of birth
and no new lesions appear. Petechiae may result from decreased platelet formation. In this
situation, the presence of petechiae is most likely a soft-tissue injury resulting from the nuchal
