Hesi Med - Surg Maternity Nclex Predictor Final
Exam 3 Real Exam Complete Verified
Questions And Correct Detailed Answers
(Verified Rationales) |Already Graded A+
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. - Correct AnswerB
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.
Page 1 of 124
,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? - Correct AnswerA
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. - Correct
AnswerB
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
Page 2 of 124
,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. - Correct AnswerB
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
Page 3 of 124
, D) Risk for infection related to transition to extrauterine environment -
Correct AnswerA
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?
A) Prevent cold stress
B) Increase surfactant levels in the lungs
C) Promote respiratory stability
D) Decrease the serum bilirubin level - Correct AnswerD
Jaundice reflects elevated serum bilirubin levels; phototherapy helps to
break down the bilirubin for excretion. Phototherapy has no effect on
body temperature, surfactant levels, or respiratory stability.
The nurse assesses a 1-day-old newborn. Which finding indicates that
the newborn's oxygen needs aren't being met?
A) Respiratory rate of 54 breaths/minute
B) Abdominal breathing
C) Nasal flaring
D) Acrocyanosis - Correct AnswerC
Page 4 of 124
Exam 3 Real Exam Complete Verified
Questions And Correct Detailed Answers
(Verified Rationales) |Already Graded A+
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. - Correct AnswerB
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.
Page 1 of 124
,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? - Correct AnswerA
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. - Correct
AnswerB
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
Page 2 of 124
,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. - Correct AnswerB
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
Page 3 of 124
, D) Risk for infection related to transition to extrauterine environment -
Correct AnswerA
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?
A) Prevent cold stress
B) Increase surfactant levels in the lungs
C) Promote respiratory stability
D) Decrease the serum bilirubin level - Correct AnswerD
Jaundice reflects elevated serum bilirubin levels; phototherapy helps to
break down the bilirubin for excretion. Phototherapy has no effect on
body temperature, surfactant levels, or respiratory stability.
The nurse assesses a 1-day-old newborn. Which finding indicates that
the newborn's oxygen needs aren't being met?
A) Respiratory rate of 54 breaths/minute
B) Abdominal breathing
C) Nasal flaring
D) Acrocyanosis - Correct AnswerC
Page 4 of 124
