Chapter 23: Nursing Care of the
Newborn and Family Perry: Maternal
Child Nursing Care, 6th Edition
. 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. - answer-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
The nurse administers vitamin K to the newborn for which reason?
a. Most mothers have a diet deficient in vitamin K, which results in the infant's 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 newborn's intestinal tract.
d. The supply of vitamin K is inadequate for at least 3 to 4 months, and the newborn
must be supplemented. - answer-ANS: C
Bacteria that synthesize vitamin K are not present in the newborn's intestinal tract.
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.
. 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. - answer-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 home visits are expensive, they
, are not available in all geographic areas. 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.
. 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. - answer-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.
. Hearing loss is one of the genetic disorders included in the universal screening
program. 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. prevention or reduction of developmental delay.
b. reassurance for concerned new parents.
c. early identification and treatment.
d. helping the child communicate better.
e. recommendation by the Joint Committee on Infant Hearing. - answer-ANS: A, C, D, E
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 who
are referred for further testing and follow-up, it is important for the nurse to provide
further explanation and emotional support. All other responses are appropriate reasons
for auditory screening of the newborn. Infants who do not pass the screening test
should have it repeated. 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.
. As part of Standard Precautions, nurses wear gloves when handling the newborn. The
chief reason is:
a. to protect the baby from infection.
b. that it is part of the Apgar protocol.
c. to protect the nurse from contamination by the newborn.
Newborn and Family Perry: Maternal
Child Nursing Care, 6th Edition
. 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. - answer-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
The nurse administers vitamin K to the newborn for which reason?
a. Most mothers have a diet deficient in vitamin K, which results in the infant's 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 newborn's intestinal tract.
d. The supply of vitamin K is inadequate for at least 3 to 4 months, and the newborn
must be supplemented. - answer-ANS: C
Bacteria that synthesize vitamin K are not present in the newborn's intestinal tract.
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.
. 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. - answer-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 home visits are expensive, they
, are not available in all geographic areas. 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.
. 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. - answer-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.
. Hearing loss is one of the genetic disorders included in the universal screening
program. 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. prevention or reduction of developmental delay.
b. reassurance for concerned new parents.
c. early identification and treatment.
d. helping the child communicate better.
e. recommendation by the Joint Committee on Infant Hearing. - answer-ANS: A, C, D, E
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 who
are referred for further testing and follow-up, it is important for the nurse to provide
further explanation and emotional support. All other responses are appropriate reasons
for auditory screening of the newborn. Infants who do not pass the screening test
should have it repeated. 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.
. As part of Standard Precautions, nurses wear gloves when handling the newborn. The
chief reason is:
a. to protect the baby from infection.
b. that it is part of the Apgar protocol.
c. to protect the nurse from contamination by the newborn.
