Maternity Nclex EXAM questions
1. Prior to discharging a 24-hour-old newborn, the A
nurse assesses her respiratory status. Which of Typically, respirations in a
the following would the nurse expect to assess? 24-hour-old newborn are symmet-
ric, slightly irregular, shallow, and
A) Respiratory rate 45, irregular unlabored at a rate of 30 to
B) Costal breathing pattern 60 breaths/minute. The breathing
C) Nasal flaring, rate 65 pattern is primarily diaphragmatic.
D) Crackles on auscultation Nasal flaring, rates above 60 breaths
per minute, and crackles suggest a
problem.
2. The nurse encourages the mother of a healthy C
newborn to put the newborn to the breast im- Breast-feeding can be initiated im-
mediately after birth for which reason? mediately after birth. This immedi-
ate mother-newborn contact takes
A) To aid in maturing the newborn's sucking advantage of the newborn's natur-
reflex al alertness and fosters bonding.
B) To encourage the development of maternal This contact also reduces maternal
antibodies bleeding and stabilizes the new-
C) To facilitate maternal-infant bonding born's temperature, blood glucose
D) To enhance the clearing of the newborn's level, and respiratory rate. It is not
respiratory passages associated with maturing the suck-
ing reflex, encouraging the develop-
ment of maternal antibodies, or aid-
ing in clearing of the newborn's res-
piratory passages.
3. When making a home visit, the nurse observes B
a newborn sleeping on his back in a bassinet. The nurse should instruct the mother
In one corner of the bassinet is a soft stuffed to remove all flutty bedding, quilts,
animal and at the other end is a bulb syringe. stutted animals, and pillows from
The nurse determines that the mother needs the crib to prevent suttocation. New-
, Maternity Nclex EXAM questions
additional teaching because of which of the fol- borns and infants should be placed
lowing? on their backs to sleep. Having the
bulb syringe nearby in the bassinet
A) The newborn should not be sleeping on his is appropriate. Although a crib is the
back. safest sleeping location, a bassinet is
B) Stuffed animals should not be in areas where appropriate initially.
infants sleep.
C) The bulb syringe should not be kept in the
bassinet.
D) This newborn should be sleeping in a crib.
4. Assessment of a newborn reveals a heart rate A
of 180 beats/minute. To determine whether this The typical heart rate of a newborn
finding is a common variation rather than a sign ranges from 120 to 160 beats per
of distress, what else does the nurse need to minute with wide fluctuation during
know? activity and sleep. Typically heart rate
is assessed every 30 minutes until
A) How many hours old is this newborn? stable for 2 hours after birth. The
B) How long ago did this newborn eat? time of the newborn's last feeding
C) What was the newborn's birthweight? and his birthweight would have no
D) Is acrocyanosis present? ettect on his heart rate. Acrocyanosis
is a common normal finding in new-
borns.
5. Just after delivery, a newborn's axillary tempera- B
ture is 94 degrees F. What action would be most A newborn's temperature is typically
appropriate? maintained at 36.5 to 37.5 degrees
C (97.7 to 99.7 degrees F). Since
A) Assess the newborn's gestational age. this newborn's temperature is signif-
B) Rewarm the newborn gradually. icantly lower, the nurse should insti-
C) Observe the newborn every hour. tute measures to rewarm the new-
born gradually. Assessment of ges-
, Maternity Nclex EXAM questions
D) Notify the physician if the temperature goes tational age is completed regard-
lower. less of the newborn's temperature.
Observation would be inappropriate
because lack of action may lead to a
further lowering of the temperature.
The nurse should notify the physi-
cian of the newborn's current tem-
perature since it is outside normal
parameters.
6. The parents of a newborn become concerned B
when they notice that their baby seems to stop Although periods of apnea of less
breathing for a few seconds. After confirming than 20 seconds can occur, the nurse
the parents' findings by observing the newborn, needs to gather additional informa-
which of the following actions would be most tion about the newborn's respiratory
appropriate? status to determine if this finding is
indicative of a developing problem.
A) Notify the health care provider immediately. Therefore, the nurse would need to
B) Assess the newborn for signs of respiratory assess for signs of respiratory dis-
distress. tress. Once this information is ob-
C) Reassure the parents that this is an expected tained, then the nurse can notify
pattern. the health care provider or explain
D) Tell the parents not to worry since his color is that this finding is an expected one.
fine. However, it would be inappropri-
ate to tell the parents not to wor-
ry, because additional information
is needed. Also, telling them not to
worry ignores their feelings and is
not therapeutic.
7. When assessing a newborn 1 hour after birth, A
the nurse measures an axillary temperature The newborn's heart rate is slight-
, Maternity Nclex EXAM questions
of 95.8 degrees F, an apical pulse of 114 ly below the accepted range of 120
beats/minute, and a respiratory rate of 60 to 160 beats/minute; the respiratory
breaths/minute. Which nursing diagnosis takes rate is at the high end of the ac-
highest priority? cepted range of 30 to 60 breaths
per minute. However, the newborn's
A) Hypothermia related to heat loss during temperature is significantly below
birthing process the accepted range of 97.7 to 99.7
B) Impaired parenting related to addition of new degrees F. Therefore, the priority
family member nursing diagnosis is hypothermia.
C) Risk for deficient fluid volume related to in- There is no information to suggest
sensible fluid loss impaired parenting. Additional in-
D) Risk for infection related to transition to ex- formation is needed to determine if
trauterine environment there is a risk for deficient fluid vol-
ume or a risk for infection.
8. The nurse places a newborn with jaundice un- D
der the phototherapy lights in the nursery to Jaundice reflects elevated serum
achieve which goal? bilirubin levels; phototherapy helps
to break down the bilirubin for ex-
A) Prevent cold stress cretion. Phototherapy has no ettect
B) Increase surfactant levels in the lungs on body temperature, surfactant lev-
C) Promote respiratory stability els, or respiratory stability.
D) Decrease the serum bilirubin level
9. The nurse assesses a 1-day-old newborn. Which C
finding indicates that the newborn's oxygen Nasal flaring is a sign of respirato-
needs aren't being met? ry diflculty in the newborn. A rate
of 54 breaths/minute, diaphragmat-
A) Respiratory rate of 54 breaths/minute ic/abdominal breathing, and acro-
B) Abdominal breathing cyanosis are normal findings.
C) Nasal flaring
D) Acrocyanosis
1. Prior to discharging a 24-hour-old newborn, the A
nurse assesses her respiratory status. Which of Typically, respirations in a
the following would the nurse expect to assess? 24-hour-old newborn are symmet-
ric, slightly irregular, shallow, and
A) Respiratory rate 45, irregular unlabored at a rate of 30 to
B) Costal breathing pattern 60 breaths/minute. The breathing
C) Nasal flaring, rate 65 pattern is primarily diaphragmatic.
D) Crackles on auscultation Nasal flaring, rates above 60 breaths
per minute, and crackles suggest a
problem.
2. The nurse encourages the mother of a healthy C
newborn to put the newborn to the breast im- Breast-feeding can be initiated im-
mediately after birth for which reason? mediately after birth. This immedi-
ate mother-newborn contact takes
A) To aid in maturing the newborn's sucking advantage of the newborn's natur-
reflex al alertness and fosters bonding.
B) To encourage the development of maternal This contact also reduces maternal
antibodies bleeding and stabilizes the new-
C) To facilitate maternal-infant bonding born's temperature, blood glucose
D) To enhance the clearing of the newborn's level, and respiratory rate. It is not
respiratory passages associated with maturing the suck-
ing reflex, encouraging the develop-
ment of maternal antibodies, or aid-
ing in clearing of the newborn's res-
piratory passages.
3. When making a home visit, the nurse observes B
a newborn sleeping on his back in a bassinet. The nurse should instruct the mother
In one corner of the bassinet is a soft stuffed to remove all flutty bedding, quilts,
animal and at the other end is a bulb syringe. stutted animals, and pillows from
The nurse determines that the mother needs the crib to prevent suttocation. New-
, Maternity Nclex EXAM questions
additional teaching because of which of the fol- borns and infants should be placed
lowing? on their backs to sleep. Having the
bulb syringe nearby in the bassinet
A) The newborn should not be sleeping on his is appropriate. Although a crib is the
back. safest sleeping location, a bassinet is
B) Stuffed animals should not be in areas where appropriate initially.
infants sleep.
C) The bulb syringe should not be kept in the
bassinet.
D) This newborn should be sleeping in a crib.
4. Assessment of a newborn reveals a heart rate A
of 180 beats/minute. To determine whether this The typical heart rate of a newborn
finding is a common variation rather than a sign ranges from 120 to 160 beats per
of distress, what else does the nurse need to minute with wide fluctuation during
know? activity and sleep. Typically heart rate
is assessed every 30 minutes until
A) How many hours old is this newborn? stable for 2 hours after birth. The
B) How long ago did this newborn eat? time of the newborn's last feeding
C) What was the newborn's birthweight? and his birthweight would have no
D) Is acrocyanosis present? ettect on his heart rate. Acrocyanosis
is a common normal finding in new-
borns.
5. Just after delivery, a newborn's axillary tempera- B
ture is 94 degrees F. What action would be most A newborn's temperature is typically
appropriate? maintained at 36.5 to 37.5 degrees
C (97.7 to 99.7 degrees F). Since
A) Assess the newborn's gestational age. this newborn's temperature is signif-
B) Rewarm the newborn gradually. icantly lower, the nurse should insti-
C) Observe the newborn every hour. tute measures to rewarm the new-
born gradually. Assessment of ges-
, Maternity Nclex EXAM questions
D) Notify the physician if the temperature goes tational age is completed regard-
lower. less of the newborn's temperature.
Observation would be inappropriate
because lack of action may lead to a
further lowering of the temperature.
The nurse should notify the physi-
cian of the newborn's current tem-
perature since it is outside normal
parameters.
6. The parents of a newborn become concerned B
when they notice that their baby seems to stop Although periods of apnea of less
breathing for a few seconds. After confirming than 20 seconds can occur, the nurse
the parents' findings by observing the newborn, needs to gather additional informa-
which of the following actions would be most tion about the newborn's respiratory
appropriate? status to determine if this finding is
indicative of a developing problem.
A) Notify the health care provider immediately. Therefore, the nurse would need to
B) Assess the newborn for signs of respiratory assess for signs of respiratory dis-
distress. tress. Once this information is ob-
C) Reassure the parents that this is an expected tained, then the nurse can notify
pattern. the health care provider or explain
D) Tell the parents not to worry since his color is that this finding is an expected one.
fine. However, it would be inappropri-
ate to tell the parents not to wor-
ry, because additional information
is needed. Also, telling them not to
worry ignores their feelings and is
not therapeutic.
7. When assessing a newborn 1 hour after birth, A
the nurse measures an axillary temperature The newborn's heart rate is slight-
, Maternity Nclex EXAM questions
of 95.8 degrees F, an apical pulse of 114 ly below the accepted range of 120
beats/minute, and a respiratory rate of 60 to 160 beats/minute; the respiratory
breaths/minute. Which nursing diagnosis takes rate is at the high end of the ac-
highest priority? cepted range of 30 to 60 breaths
per minute. However, the newborn's
A) Hypothermia related to heat loss during temperature is significantly below
birthing process the accepted range of 97.7 to 99.7
B) Impaired parenting related to addition of new degrees F. Therefore, the priority
family member nursing diagnosis is hypothermia.
C) Risk for deficient fluid volume related to in- There is no information to suggest
sensible fluid loss impaired parenting. Additional in-
D) Risk for infection related to transition to ex- formation is needed to determine if
trauterine environment there is a risk for deficient fluid vol-
ume or a risk for infection.
8. The nurse places a newborn with jaundice un- D
der the phototherapy lights in the nursery to Jaundice reflects elevated serum
achieve which goal? bilirubin levels; phototherapy helps
to break down the bilirubin for ex-
A) Prevent cold stress cretion. Phototherapy has no ettect
B) Increase surfactant levels in the lungs on body temperature, surfactant lev-
C) Promote respiratory stability els, or respiratory stability.
D) Decrease the serum bilirubin level
9. The nurse assesses a 1-day-old newborn. Which C
finding indicates that the newborn's oxygen Nasal flaring is a sign of respirato-
needs aren't being met? ry diflculty in the newborn. A rate
of 54 breaths/minute, diaphragmat-
A) Respiratory rate of 54 breaths/minute ic/abdominal breathing, and acro-
B) Abdominal breathing cyanosis are normal findings.
C) Nasal flaring
D) Acrocyanosis
