1. Prior to discharging a 24-hour-old newborn, the nurse assesses her
respiratory status. Which of the following would the nurse expect to assess?
A) Respiratory rate 45, irregular
B) Costal breathing pattern
C) Nasal flaring, rate 65
D) Crackles on auscultation: A
Typically, respirations in a 24-hour-old newborn are symmetric, slightly irregular,
shallow, and unlabored at a rate of 30 to 60 breaths/minute. The breathing pattern
is primarily diaphragmatic. Nasal flaring, rates above 60 breaths per minute, and
crackles suggest a problem.
2. The nurse encourages the mother of a healthy newborn to put the newborn
to the breast immediately after birth for which reason?
A) To aid in maturing the newborn's sucking reflex
B) To encourage the development of maternal antibodies
C) To facilitate maternal-infant bonding
D) To enhance the clearing of the newborn's respiratory passages: C
Breast-feeding can be initiated immediately after birth. This immediate mother-
newborn contact takes advantage of the newborn's natural alertness and fosters
bonding. This contact also reduces maternal bleeding and stabilizes the newborn's
temperature, blood glucose level, and respiratory rate. It is not associated with
maturing the sucking reflex, encouraging the development of maternal antibodies,
or aiding in clearing of the newborn's respiratory passages.
3. 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 stuffed animal and
at the other end is a bulb syringe. The nurse determines that the mother needs
additional teaching because of which of the following?
A) The newborn should not be sleeping on his back.
B) Stuffed animals should not be in areas where infants sleep.
C) The bulb syringe should not be kept in the bassinet.
D) This newborn should be sleeping in a crib.: B
,The nurse should instruct the mother to remove all fluffy bedding, quilts, stuffed
animals, and pillows from the crib to prevent suffocation. Newborns and infants
should be placed on their backs to sleep. Having the bulb syringe nearby in the
bassinet is appropriate. Although a crib is the safest sleeping location, a bassinet
is appropriate initially.
4. Assessment of a newborn reveals a heart rate of 180 beats/minute. To
determine whether this finding is a common variation rather than a sign of
distress, what else does the nurse need to know?
A) How many hours old is this newborn?
B) How long ago did this newborn eat?
C) What was the newborn's birthweight?
D) Is acrocyanosis present?: A
The typical heart rate of a newborn ranges from 120 to 160 beats per minute with
wide fluctuation during activity and sleep. Typically heart rate is assessed every 30
minutes until stable for 2 hours after birth. The time of the newborn's last feeding
and his birthweight would have no effect on his heart rate. Acrocyanosis is a
common normal finding in newborns.
5. Just after delivery, a newborn's axillary temperature is 94 degrees F. What
action would be most appropriate?
A) Assess the newborn's gestational age.
B) Rewarm the newborn gradually.
C) Observe the newborn every hour.
D) Notify the physician if the temperature goes lower.: B
A newborn's temperature is typically maintained at 36.5 to 37.5 degrees C (97.7 to
99.7 degrees F). Since this newborn's temperature is significantly lower, the nurse
should institute measures to rewarm the newborn gradually. Assessment of
gestational age is completed regardless 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 physician of the
newborn's current temperature since it is outside normal parameters.
6. The parents of a newborn become concerned when they notice that their
baby seems to stop breathing for a few seconds. After confirming the parents'
, findings by observing the newborn, which of the following actions would be
most appropriate?
A) Notify the health care provider immediately.
B) Assess the newborn for signs of respiratory distress.
C) Reassure the parents that this is an expected pattern.
D) Tell the parents not to worry since his color is fine.: B
Although periods of apnea of less than 20 seconds can occur, the nurse needs to
gather additional information about the newborn's respiratory status to determine if
this finding is indicative of a developing problem. Therefore, the nurse would need
to assess for signs of respiratory distress. Once this information is obtained, then
the nurse can notify the health care provider or explain that this finding is an
expected one. However, it would be inappropriate to tell the parents not to worry,
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, the nurse measures an
axillary temperature of 95.8 degrees F, an apical pulse of 114 beats/minute,
and a respiratory rate of 60 breaths/minute. Which nursing diagnosis takes
highest priority?
A) Hypothermia related to heat loss during birthing process
B) Impaired parenting related to addition of new family member
C) Risk for deficient fluid volume related to insensible fluid loss
D) Risk for infection related to transition to extrauterine environment: A The
newborn's heart rate is slightly below the accepted 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 minute. However, the newborn's temperature is significantly
below the accepted range of 97.7 to 99.7 degrees F. Therefore, the priority
nursing diagnosis is hypothermia. There is no information to suggest impaired
parenting. Additional information is needed to determine if there is a risk for
deficient fluid volume or a risk for infection.
8. The nurse places a newborn with jaundice under the phototherapy lights in
the nursery to achieve which goal?
A) Prevent cold stress
respiratory status. Which of the following would the nurse expect to assess?
A) Respiratory rate 45, irregular
B) Costal breathing pattern
C) Nasal flaring, rate 65
D) Crackles on auscultation: A
Typically, respirations in a 24-hour-old newborn are symmetric, slightly irregular,
shallow, and unlabored at a rate of 30 to 60 breaths/minute. The breathing pattern
is primarily diaphragmatic. Nasal flaring, rates above 60 breaths per minute, and
crackles suggest a problem.
2. The nurse encourages the mother of a healthy newborn to put the newborn
to the breast immediately after birth for which reason?
A) To aid in maturing the newborn's sucking reflex
B) To encourage the development of maternal antibodies
C) To facilitate maternal-infant bonding
D) To enhance the clearing of the newborn's respiratory passages: C
Breast-feeding can be initiated immediately after birth. This immediate mother-
newborn contact takes advantage of the newborn's natural alertness and fosters
bonding. This contact also reduces maternal bleeding and stabilizes the newborn's
temperature, blood glucose level, and respiratory rate. It is not associated with
maturing the sucking reflex, encouraging the development of maternal antibodies,
or aiding in clearing of the newborn's respiratory passages.
3. 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 stuffed animal and
at the other end is a bulb syringe. The nurse determines that the mother needs
additional teaching because of which of the following?
A) The newborn should not be sleeping on his back.
B) Stuffed animals should not be in areas where infants sleep.
C) The bulb syringe should not be kept in the bassinet.
D) This newborn should be sleeping in a crib.: B
,The nurse should instruct the mother to remove all fluffy bedding, quilts, stuffed
animals, and pillows from the crib to prevent suffocation. Newborns and infants
should be placed on their backs to sleep. Having the bulb syringe nearby in the
bassinet is appropriate. Although a crib is the safest sleeping location, a bassinet
is appropriate initially.
4. Assessment of a newborn reveals a heart rate of 180 beats/minute. To
determine whether this finding is a common variation rather than a sign of
distress, what else does the nurse need to know?
A) How many hours old is this newborn?
B) How long ago did this newborn eat?
C) What was the newborn's birthweight?
D) Is acrocyanosis present?: A
The typical heart rate of a newborn ranges from 120 to 160 beats per minute with
wide fluctuation during activity and sleep. Typically heart rate is assessed every 30
minutes until stable for 2 hours after birth. The time of the newborn's last feeding
and his birthweight would have no effect on his heart rate. Acrocyanosis is a
common normal finding in newborns.
5. Just after delivery, a newborn's axillary temperature is 94 degrees F. What
action would be most appropriate?
A) Assess the newborn's gestational age.
B) Rewarm the newborn gradually.
C) Observe the newborn every hour.
D) Notify the physician if the temperature goes lower.: B
A newborn's temperature is typically maintained at 36.5 to 37.5 degrees C (97.7 to
99.7 degrees F). Since this newborn's temperature is significantly lower, the nurse
should institute measures to rewarm the newborn gradually. Assessment of
gestational age is completed regardless 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 physician of the
newborn's current temperature since it is outside normal parameters.
6. The parents of a newborn become concerned when they notice that their
baby seems to stop breathing for a few seconds. After confirming the parents'
, findings by observing the newborn, which of the following actions would be
most appropriate?
A) Notify the health care provider immediately.
B) Assess the newborn for signs of respiratory distress.
C) Reassure the parents that this is an expected pattern.
D) Tell the parents not to worry since his color is fine.: B
Although periods of apnea of less than 20 seconds can occur, the nurse needs to
gather additional information about the newborn's respiratory status to determine if
this finding is indicative of a developing problem. Therefore, the nurse would need
to assess for signs of respiratory distress. Once this information is obtained, then
the nurse can notify the health care provider or explain that this finding is an
expected one. However, it would be inappropriate to tell the parents not to worry,
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, the nurse measures an
axillary temperature of 95.8 degrees F, an apical pulse of 114 beats/minute,
and a respiratory rate of 60 breaths/minute. Which nursing diagnosis takes
highest priority?
A) Hypothermia related to heat loss during birthing process
B) Impaired parenting related to addition of new family member
C) Risk for deficient fluid volume related to insensible fluid loss
D) Risk for infection related to transition to extrauterine environment: A The
newborn's heart rate is slightly below the accepted 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 minute. However, the newborn's temperature is significantly
below the accepted range of 97.7 to 99.7 degrees F. Therefore, the priority
nursing diagnosis is hypothermia. There is no information to suggest impaired
parenting. Additional information is needed to determine if there is a risk for
deficient fluid volume or a risk for infection.
8. The nurse places a newborn with jaundice under the phototherapy lights in
the nursery to achieve which goal?
A) Prevent cold stress
