PERRY’S MATERNAL CHILD
NURSING CARE (PHYSIOLOGIC
AND BEHAVIORAL ADAPTATIONS OF
THE NEWBORN) EXAM QUESTIONS
AND THEIR VERIFIED WELL
EXPLAINED ANSWERS
1. A woman gave birth to a healthy 7-lb, 13-ounce
infant girl. The nurse suggests that the woman place
the infant to her breast within 15 minutes after birth.
The nurse knows that breastfeeding is effective during
the first 30 minutes after birth because this is the:
a. transition period.
b. first period of reactivity.
c. organizational stage.
d. second period of reactivity.
ANS: B
The first period of reactivity is the first phase of transition
and lasts up to 30 minutes after birth. The infant is highly
alert during this phase. The transition period is the phase
between intrauterine and extrauterine existence. There is
no such phase as the organizational stage. The second
period of reactivity occurs roughly between 4 and 8 hours
after birth, after a period of prolonged sleep.
2. Part of the health assessment of a newborn is
observing the infant's breathing pattern. A full-term
,newborn's breathing pattern is predominantly:
a. abdominal with synchronous chest movements.
b. chest breathing with nasal flaring.
c. diaphragmatic with chest retraction.
d. deep with a regular rhythm.
ANS: A
In normal infant respiration the chest and abdomen rise
synchronously, and breaths are shallow and irregular.
Breathing with nasal flaring is a sign of respiratory
distress. Diaphragmatic breathing with chest retraction is a
sign of respiratory distress. Infant breaths are not deep
with a regular rhythm.
3. While assessing the newborn, the nurse should be
aware that the average expected apical pulse range of
a full-term, quiet, alert newborn is:
a. 80 to 100 beats/min.
b. 100 to 120 beats/min.
c. 120 to 160 beats/min.
d. 150 to 180 beats/min.
ANS: C
The average infant heart rate while awake is 120 to 160
beats/min. The newborn's heart rate may be about 85 to
100 beats/min while sleeping. The infant's heart rate
typically is a bit higher when alert but quiet. A heart rate of
150 to 180 beats/min is typical when the infant cries.
4. A newborn is placed under a radiant heat warmer,
and the nurse evaluates the infant's body temperature
every hour. Maintaining the newborn's body
temperature is important for preventing:
a. respiratory depression.
b. cold stress.
, c. tachycardia.
d. vasoconstriction.
ANS: B
Loss of heat must be controlled to protect the infant from
the metabolic and physiologic effects of cold stress, and
that is the primary reason for placing a newborn under a
radiant heat warmer. Cold stress results in an increased
respiratory rate and vasoconstriction.
5. An African-American woman noticed some bruises
on her newborn girl's buttocks. She asks the nurse
who spanked her daughter. The nurse explains that
these marks are called:
a. lanugo.
b. vascular nevi.
c. nevus flammeus.
d. Mongolian spots.
ANS: D
A Mongolian spot is a bluish black area of pigmentation
that may appear over any part of the exterior surface of
the body. It is more commonly noted on the back and
buttocks and most frequently is seen on infants whose
ethnic origins are Mediterranean, Latin American, Asian,
or African. Lanugo is the fine, downy hair seen on a term
newborn. A vascular nevus, commonly called a strawberry
mark, is a type of capillary hemangioma. A nevus
flammeus, commonly called a port-wine stain, is most
frequently found on the face.
6. While examining a newborn, the nurse notes
uneven skinfolds on the buttocks and a click when
performing the Ortolani maneuver. The nurse
recognizes these findings as a sign that the newborn
NURSING CARE (PHYSIOLOGIC
AND BEHAVIORAL ADAPTATIONS OF
THE NEWBORN) EXAM QUESTIONS
AND THEIR VERIFIED WELL
EXPLAINED ANSWERS
1. A woman gave birth to a healthy 7-lb, 13-ounce
infant girl. The nurse suggests that the woman place
the infant to her breast within 15 minutes after birth.
The nurse knows that breastfeeding is effective during
the first 30 minutes after birth because this is the:
a. transition period.
b. first period of reactivity.
c. organizational stage.
d. second period of reactivity.
ANS: B
The first period of reactivity is the first phase of transition
and lasts up to 30 minutes after birth. The infant is highly
alert during this phase. The transition period is the phase
between intrauterine and extrauterine existence. There is
no such phase as the organizational stage. The second
period of reactivity occurs roughly between 4 and 8 hours
after birth, after a period of prolonged sleep.
2. Part of the health assessment of a newborn is
observing the infant's breathing pattern. A full-term
,newborn's breathing pattern is predominantly:
a. abdominal with synchronous chest movements.
b. chest breathing with nasal flaring.
c. diaphragmatic with chest retraction.
d. deep with a regular rhythm.
ANS: A
In normal infant respiration the chest and abdomen rise
synchronously, and breaths are shallow and irregular.
Breathing with nasal flaring is a sign of respiratory
distress. Diaphragmatic breathing with chest retraction is a
sign of respiratory distress. Infant breaths are not deep
with a regular rhythm.
3. While assessing the newborn, the nurse should be
aware that the average expected apical pulse range of
a full-term, quiet, alert newborn is:
a. 80 to 100 beats/min.
b. 100 to 120 beats/min.
c. 120 to 160 beats/min.
d. 150 to 180 beats/min.
ANS: C
The average infant heart rate while awake is 120 to 160
beats/min. The newborn's heart rate may be about 85 to
100 beats/min while sleeping. The infant's heart rate
typically is a bit higher when alert but quiet. A heart rate of
150 to 180 beats/min is typical when the infant cries.
4. A newborn is placed under a radiant heat warmer,
and the nurse evaluates the infant's body temperature
every hour. Maintaining the newborn's body
temperature is important for preventing:
a. respiratory depression.
b. cold stress.
, c. tachycardia.
d. vasoconstriction.
ANS: B
Loss of heat must be controlled to protect the infant from
the metabolic and physiologic effects of cold stress, and
that is the primary reason for placing a newborn under a
radiant heat warmer. Cold stress results in an increased
respiratory rate and vasoconstriction.
5. An African-American woman noticed some bruises
on her newborn girl's buttocks. She asks the nurse
who spanked her daughter. The nurse explains that
these marks are called:
a. lanugo.
b. vascular nevi.
c. nevus flammeus.
d. Mongolian spots.
ANS: D
A Mongolian spot is a bluish black area of pigmentation
that may appear over any part of the exterior surface of
the body. It is more commonly noted on the back and
buttocks and most frequently is seen on infants whose
ethnic origins are Mediterranean, Latin American, Asian,
or African. Lanugo is the fine, downy hair seen on a term
newborn. A vascular nevus, commonly called a strawberry
mark, is a type of capillary hemangioma. A nevus
flammeus, commonly called a port-wine stain, is most
frequently found on the face.
6. While examining a newborn, the nurse notes
uneven skinfolds on the buttocks and a click when
performing the Ortolani maneuver. The nurse
recognizes these findings as a sign that the newborn
