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Maternity Nclex questions & answers.
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Maternity Nclex questions & answers.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 ANS - 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.
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 ANS - 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.
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. ANS - 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.
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? ANS - 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.
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. ANS - 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.
, 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. ANS - 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.
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 ANS - 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.
The nurse places a newborn with jaundice under the phototherapy lights in the nursery to achieve which
goal?
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