Maternity NCLEX Questions and Answers Graded A+
Prior to discharging a 24-hour-old newborn, the nurse
assesses her respiratory status. Which of the following A
would the nurse expect to assess? Typically, respirations in a 24-hour-old newborn are sym-
metric, slightly irregular, shallow, and unlabored at a rate
A) Respiratory rate 45, irregular of 30 to 60 breaths/minute. The breathing pattern is
B) Costal breathing pattern primarily diaphragmatic. Nasal flaring, rates above 60
C) Nasal flaring, rate 65 breaths per minute, and crackles suggest a problem.
D) Crackles on auscultation
The nurse encourages the mother of a healthy newborn C
to put the newborn to the breast immediately after birth Breast-feeding can be initiated immediately after birth.
for which reason? This immediate mother-newborn contact takes advantage
of the newborn's natural alertness and fosters bonding.
A) To aid in maturing the newborn's sucking This contact also reduces maternal bleeding and stabi-
reflex lizes the newborn's temperature, blood glucose level, and
B) To encourage the development of maternal antibodies respiratory rate. It is not associated with maturing the
C) To facilitate maternal-infant bonding sucking reflex, encouraging the development of maternal
D) To enhance the clearing of the newborn's respiratory antibodies, or aiding in clearing of the newborn's respira-
passages tory passages.
When making a home visit, the nurse observes a newborn
sleeping on his back in a bassinet. In one corner of the
bassinet is a soft stutted animal and at the other end is a B
bulb syringe. The nurse determines that the mother needs The nurse should instruct the mother to remove all flutty
additional teaching because of which of the following? bedding, quilts, stutted animals, and pillows from the crib
to prevent suttocation. Newborns and infants should be
A) The newborn should not be sleeping on his back. placed on their backs to sleep. Having the bulb syringe
B) Stutted animals should not be in areas where infants nearby in the bassinet is appropriate. Although a crib is the
sleep. safest sleeping location, a bassinet is appropriate initially.
C) The bulb syringe should not be kept in the bassinet.
D) This newborn should be sleeping in a crib.
Assessment of a newborn reveals a heart rate of 180
beats/minute. To determine whether this finding is a
, Maternity NCLEX Questions and Answers Graded A+
A
common variation rather than a sign of distress, what else
The typical heart rate of a newborn ranges from 120 to 160
does the nurse need to know?
beats per minute with wide fluctuation during activity and
sleep. Typically heart rate is assessed every 30 minutes un-
A) How many hours old is this newborn?
til stable for 2 hours after birth. The time of the newborn's
B) How long ago did this newborn eat?
last feeding and his birthweight would have no ettect on
C) What was the newborn's birthweight?
his heart rate. Acrocyanosis is a common normal finding
D) Is acrocyanosis present?
in newborns.
B
A newborn's temperature is typically maintained at 36.5
Just after delivery, a newborn's axillary temperature is 94 to 37.5 degrees C (97.7 to 99.7 degrees F). Since this
degrees F. What action would be most appropriate? newborn's temperature is significantly lower, the nurse
should institute measures to rewarm the newborn gradu-
A) Assess the newborn's gestational age. ally. Assessment of gestational age is completed regard-
B) Rewarm the newborn gradually. less of the newborn's temperature. Observation would be
C) Observe the newborn every hour. inappropriate because lack of action may lead to a further
D) Notify the physician if the temperature goes lower. lowering of the temperature. The nurse should notify the
physician of the newborn's current temperature since it is
outside normal parameters.
B
The parents of a newborn become concerned when they Although periods of apnea of less than 20 seconds can
notice that their baby seems to stop breathing for a few occur, the nurse needs to gather additional information
seconds. After confirming the parents' findings by observ- about the newborn's respiratory status to determine if this
ing the newborn, which of the following actions would be finding is indicative of a developing problem. Therefore,
most appropriate? the nurse would need to assess for signs of respiratory
distress. Once this information is obtained, then the nurse
A) Notify the health care provider immediately. can notify the health care provider or explain that this
B) Assess the newborn for signs of respiratory distress. finding is an expected one. However, it would be inappro-
C) Reassure the parents that this is an expected pattern. priate to tell the parents not to worry, because additional
D) Tell the parents not to worry since his color is fine. information is needed. Also, telling them not to worry
ignores their feelings and is not therapeutic.
, Maternity NCLEX Questions and Answers Graded A+
When assessing a newborn 1 hour after birth, the nurse
measures an axillary temperature of 95.8 degrees F, an
apical pulse of 114 beats/minute, and a respiratory rate of A
60 breaths/minute. Which nursing diagnosis takes high- The newborn's heart rate is slightly below the accepted
est priority? range of 120 to 160 beats/minute; the respiratory rate is at
the high end of the accepted range of 30 to 60 breaths per
A) Hypothermia related to heat loss during birthing minute. However, the newborn's temperature is signifi-
process cantly below the accepted range of 97.7 to 99.7 degrees F.
B) Impaired parenting related to addition of new family Therefore, the priority nursing diagnosis is hypothermia.
member There is no information to suggest impaired parenting.
C) Risk for deficient fluid volume related to insensible fluid Additional information is needed to determine if there is
loss a risk for deficient fluid volume or a risk for infection.
D) Risk for infection related to transition to extrauterine
environment
The nurse places a newborn with jaundice under the
phototherapy lights in the nursery to achieve which goal? D
Jaundice reflects elevated serum bilirubin levels; pho-
A) Prevent cold stress totherapy helps to break down the bilirubin for excretion.
B) Increase surfactant levels in the lungs Phototherapy has no ettect on body temperature, surfac-
C) Promote respiratory stability tant levels, or respiratory stability.
D) Decrease the serum bilirubin level
The nurse assesses a 1-day-old newborn. Which finding
indicates that the newborn's oxygen needs aren't being
met? C
Nasal flaring is a sign of respiratory diflculty in the new-
A) Respiratory rate of 54 breaths/minute born. A rate of 54 breaths/minute, diaphragmatic/ab-
B) Abdominal breathing dominal breathing, and acrocyanosis are normal findings.
C) Nasal flaring
D) Acrocyanosis
During a physical assessment of a newborn, the nurse ob- B
serves bluish markings across the newborn's lower back. Mongolian spots are blue or purple splotches that ap-
Prior to discharging a 24-hour-old newborn, the nurse
assesses her respiratory status. Which of the following A
would the nurse expect to assess? Typically, respirations in a 24-hour-old newborn are sym-
metric, slightly irregular, shallow, and unlabored at a rate
A) Respiratory rate 45, irregular of 30 to 60 breaths/minute. The breathing pattern is
B) Costal breathing pattern primarily diaphragmatic. Nasal flaring, rates above 60
C) Nasal flaring, rate 65 breaths per minute, and crackles suggest a problem.
D) Crackles on auscultation
The nurse encourages the mother of a healthy newborn C
to put the newborn to the breast immediately after birth Breast-feeding can be initiated immediately after birth.
for which reason? This immediate mother-newborn contact takes advantage
of the newborn's natural alertness and fosters bonding.
A) To aid in maturing the newborn's sucking This contact also reduces maternal bleeding and stabi-
reflex lizes the newborn's temperature, blood glucose level, and
B) To encourage the development of maternal antibodies respiratory rate. It is not associated with maturing the
C) To facilitate maternal-infant bonding sucking reflex, encouraging the development of maternal
D) To enhance the clearing of the newborn's respiratory antibodies, or aiding in clearing of the newborn's respira-
passages tory passages.
When making a home visit, the nurse observes a newborn
sleeping on his back in a bassinet. In one corner of the
bassinet is a soft stutted animal and at the other end is a B
bulb syringe. The nurse determines that the mother needs The nurse should instruct the mother to remove all flutty
additional teaching because of which of the following? bedding, quilts, stutted animals, and pillows from the crib
to prevent suttocation. Newborns and infants should be
A) The newborn should not be sleeping on his back. placed on their backs to sleep. Having the bulb syringe
B) Stutted animals should not be in areas where infants nearby in the bassinet is appropriate. Although a crib is the
sleep. safest sleeping location, a bassinet is appropriate initially.
C) The bulb syringe should not be kept in the bassinet.
D) This newborn should be sleeping in a crib.
Assessment of a newborn reveals a heart rate of 180
beats/minute. To determine whether this finding is a
, Maternity NCLEX Questions and Answers Graded A+
A
common variation rather than a sign of distress, what else
The typical heart rate of a newborn ranges from 120 to 160
does the nurse need to know?
beats per minute with wide fluctuation during activity and
sleep. Typically heart rate is assessed every 30 minutes un-
A) How many hours old is this newborn?
til stable for 2 hours after birth. The time of the newborn's
B) How long ago did this newborn eat?
last feeding and his birthweight would have no ettect on
C) What was the newborn's birthweight?
his heart rate. Acrocyanosis is a common normal finding
D) Is acrocyanosis present?
in newborns.
B
A newborn's temperature is typically maintained at 36.5
Just after delivery, a newborn's axillary temperature is 94 to 37.5 degrees C (97.7 to 99.7 degrees F). Since this
degrees F. What action would be most appropriate? newborn's temperature is significantly lower, the nurse
should institute measures to rewarm the newborn gradu-
A) Assess the newborn's gestational age. ally. Assessment of gestational age is completed regard-
B) Rewarm the newborn gradually. less of the newborn's temperature. Observation would be
C) Observe the newborn every hour. inappropriate because lack of action may lead to a further
D) Notify the physician if the temperature goes lower. lowering of the temperature. The nurse should notify the
physician of the newborn's current temperature since it is
outside normal parameters.
B
The parents of a newborn become concerned when they Although periods of apnea of less than 20 seconds can
notice that their baby seems to stop breathing for a few occur, the nurse needs to gather additional information
seconds. After confirming the parents' findings by observ- about the newborn's respiratory status to determine if this
ing the newborn, which of the following actions would be finding is indicative of a developing problem. Therefore,
most appropriate? the nurse would need to assess for signs of respiratory
distress. Once this information is obtained, then the nurse
A) Notify the health care provider immediately. can notify the health care provider or explain that this
B) Assess the newborn for signs of respiratory distress. finding is an expected one. However, it would be inappro-
C) Reassure the parents that this is an expected pattern. priate to tell the parents not to worry, because additional
D) Tell the parents not to worry since his color is fine. information is needed. Also, telling them not to worry
ignores their feelings and is not therapeutic.
, Maternity NCLEX Questions and Answers Graded A+
When assessing a newborn 1 hour after birth, the nurse
measures an axillary temperature of 95.8 degrees F, an
apical pulse of 114 beats/minute, and a respiratory rate of A
60 breaths/minute. Which nursing diagnosis takes high- The newborn's heart rate is slightly below the accepted
est priority? range of 120 to 160 beats/minute; the respiratory rate is at
the high end of the accepted range of 30 to 60 breaths per
A) Hypothermia related to heat loss during birthing minute. However, the newborn's temperature is signifi-
process cantly below the accepted range of 97.7 to 99.7 degrees F.
B) Impaired parenting related to addition of new family Therefore, the priority nursing diagnosis is hypothermia.
member There is no information to suggest impaired parenting.
C) Risk for deficient fluid volume related to insensible fluid Additional information is needed to determine if there is
loss a risk for deficient fluid volume or a risk for infection.
D) Risk for infection related to transition to extrauterine
environment
The nurse places a newborn with jaundice under the
phototherapy lights in the nursery to achieve which goal? D
Jaundice reflects elevated serum bilirubin levels; pho-
A) Prevent cold stress totherapy helps to break down the bilirubin for excretion.
B) Increase surfactant levels in the lungs Phototherapy has no ettect on body temperature, surfac-
C) Promote respiratory stability tant levels, or respiratory stability.
D) Decrease the serum bilirubin level
The nurse assesses a 1-day-old newborn. Which finding
indicates that the newborn's oxygen needs aren't being
met? C
Nasal flaring is a sign of respiratory diflculty in the new-
A) Respiratory rate of 54 breaths/minute born. A rate of 54 breaths/minute, diaphragmatic/ab-
B) Abdominal breathing dominal breathing, and acrocyanosis are normal findings.
C) Nasal flaring
D) Acrocyanosis
During a physical assessment of a newborn, the nurse ob- B
serves bluish markings across the newborn's lower back. Mongolian spots are blue or purple splotches that ap-
