Maternal Chapter 26: Nursing Care of the
Newborn and Family
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 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.
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 Staphylococcus that 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 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.
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 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.
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. They are benign if they disappear within 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 ANS: A
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
cord at birth. Unless they do not dissipate in 2 days, there is no reason for the family to be
alarmed. Petechiae usually occur with a breech presentation vaginal birth.
A newborn is jaundiced and receiving phototherapy via ultraviolet bank lights. Which is an
appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving
phototherapy?
a. Apply an oil-based lotion to the newborn's skin to prevent dying and cracking.
b. Limit the newborn's intake of milk to prevent nausea, vomiting, and diarrhea.
c. Place eye shields over the newborn's closed eyes.
d. Change the newborn's position every 4 hours. - ANS ANS: C
The infant's eyes must be protected by an opaque mask to prevent overexposure to the light.
Eye shields should cover the eyes completely but not occlude the nares. Lotions and ointments
should not be applied to the infant because they absorb heat, and this can cause burns. The
lights increase insensible water loss, placing the infant at risk for fluid loss and dehydration.
Therefore, it is important that the infant be adequately hydrated. The infant should be turned
every 2 hours to expose all body surfaces to the light.
Early this morning, an infant boy was circumcised using the PlastiBell method. When should the
nurse tell the mother that she and her infant can be discharged?
a. The bleeding stops completely.
b. Yellow exudate forms over the glans.
c. The PlastiBell rim falls off.
d. The infant voids. - ANS ANS: D
The infant should be observed for urination after the circumcision. Bleeding is a common
complication after circumcision. The nurse will check the penis for 12 hours after a circumcision
to assess and provide appropriate interventions for prevention and treatment of bleeding. Yellow
exudates cover the glans penis within 24 hours after the circumcision. This is part of normal
healing and not an infective process. The PlastiBell remains in place for about a week and falls
off when healing has taken place.
A mother expresses fear about changing her infant's diaper after he is circumcised with a
Gomco clamp. What does the woman need to be taught, in order to take care of the infant when
she gets home?
a. Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours.
b. Apply constant, firm pressure by squeezing the penis with the fingers for at least 5 minutes if
bleeding occurs.
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