Chapter 23: Nursing Care of the Newborn and Family Perry: Maternal Child Nursing Care, 6th Edition

Chapter 23:
Nursing Care of
the Newborn
and Family
Perry: Maternal
Child Nursing
Care, 6th
Edition
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. - 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
2. A new father wants to know what
medication was put into his infant's eyes
and why it is needed. The nurse explains to
the father that the purpose of the
erythromycin 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 infant's eyes potentially
acquired from the birth canal.
c. prevent potentially harmful exudate from
invading the tear ducts of the infant's eyes,
leading to dry eyes.
d. prevent the infant's eyelids from sticking
together and help the infant see. -
ANSWER-ANS: B
The purpose of the erythromycin
ophthalmic ointment is to prevent
gonorrheal and chlamydial infection of the
infant's eyes 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.
3. A 3.8-kg infant was delivered vaginally at
39 weeks after a 30-minute second stage.
There was a nuchal cord. After birth the
infant is noted to have petechiae over the
face and upper back. Information given to
the infant's parents should be based on the
knowledge that petechiae:
a. are benign if they disappear within 48
hours of birth.
b. result from increased blood volume.
c. should always be further investigated.
d. usually occur with forceps delivery. -
ANSWER-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 softtissue injury resulting from the nuchal cord
at birth. Unless they do not dissipate in 2
days, there is no reason to alarm the family.
Petechiae usually occur with a breech
presentation vaginal birth.