MATERNAL CHILD NURSING CARE
EXAM 2025 WITH CORRECT ANSWERS
Chapter 22: Physiologic and Behavioral Adaptations of the Newborn
d d d d d d d d
Perry: Maternal Child Nursing Care, 6th Edition
d d d d d d
MULTIPLE CHOICE d
1. A woman gave birth to a healthy 7-lb, 13-ounce infant girl. The nurse suggests that the
d d d d d d d d d d d d d d d d
woman place the infant to her breast within 15 minutes after birth. The nurse knows that
d d d d d d d d d d d d d d d
breastfeeding is effective during the first 30 minutes after birth because this is the:
d d d d d d d d d d d d d
a. transition period.
d d
b. first period of reactivity.
d d d d
c. organizational stage.
d d
d. second period of reactivity. - correct answer ANS: B
d d d d d d d d d
The first period of reactivity is the first phase of transition and lasts up to 30 minutes after
d d d d d d d d d d d d d d d d d
birth. The infant is highly alert during this phase. The transition period is the phase between
d d d d d d d d d d d d d d d
intrauterine and extrauterine existence. There is no such phase as the organizational stage.
d d d d d d d d d d d d d
The
second period of reactivity occurs roughly between 4 and 8 hours after birth, after a period of
d d d d d d d d d d d d d d d d
prolonged sleep. d
PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Planning
d d d d d d d d d
MSC: Client Needs: Health Promotion and Maintenance
d d d d d d
,2. Part of the health assessment of a newborn is observing the infant's breathing pattern. A
d d d d d d d d d d d d d d d
full-term newborn's breathing pattern is predominantly: d d d d d
a. abdominal with synchronous chest movements.
d d d d d
b. chest breathing with nasal flaring.
d d d d d
c. diaphragmatic with chest retraction.
d d d d
d. deep with a regular rhythm. - correct answer ANS: A
d d d d d d d d d d
In normal infant respiration the chest and abdomen rise synchronously, and breaths are
d d d d d d d d d d d d
shallow and irregular. Breathing with nasal flaring is a sign of respiratory distress.
d d d d d d d d d d d d
Diaphragmatic breathing with chest retraction is a sign of respiratory distress. Infant breaths d d d d d d d d d d d d
are not deep with a regular rhythm.
d d d d d d
PTS: 1 DIF: Cognitive Level: Comprehension
d d d d d
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
d d d d d d d d
3. While assessing the newborn, the nurse should be aware that the average expected apical
d d d d d d d d d d d d d d
pulse range of a full-term, quiet, alert newborn is:
d d d d d d d d
a. 80 to 100 beats/min.
d d d d
b. 100 to 120 beats/min.
d d d d
c. 120 to 160 beats/min.
d d d d
d. 150 to 180 beats/min. - correct answer ANS: C
d d d d d d d d d
The average infant heart rate while awake is 120 to 160 beats/min. The newborn's heart rate
d d d d d d d d d d d d d d d
may be about 85 to 100 beats/min while sleeping. The infant's heart rate typically is a bit
d d d d d d d d d d d d d d d d
higher when alert but quiet. A heart rate of 150 to 180 beats/min is typical when the infant
d d d d d d d d d d d d d d d d d
cries.
PTS: 1 DIF: Cognitive Level: Comprehension
d d d d d
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
d d d d d d d d d d
4. A newborn is placed under a radiant heat warmer, and the nurse evaluates the infant's body
d d d d d d d d d d d d d d d d
temperature every hour. Maintaining the newborn's body temperature is important for d d d d d d d d d d
preventing:
a. respiratory depression.
d d
b. cold stress.
d d
c. tachycardia.
d
d. vasoconstriction. - correct answer ANS: B
d d d d d d
Loss of heat must be controlled to protect the infant from the metabolic and physiologic
d d d d d d d d d d d d d d
effects of cold stress, and that is the primary reason for placing a newborn under a radiant heat
d d d d d d d d d d d d d d d d d
warmer. Cold stress results in an increased respiratory rate and vasoconstriction. d d d d d d d d d d
PTS: 1 DIF: Cognitive Level: Comprehension
d d d d d
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
d d d d d d d d
5. An African-American woman noticed some bruises on her newborn girl's buttocks. She
d d d d d d d d d d d d d
asks
the nurse who spanked her daughter. The nurse explains that these marks are called:
d d d d d d d d d d d d d
a. lanugo.
d
b. vascular nevi.
d d
c. nevus flammeus.
d d
d. Mongolian spots - correct answer .
d d d d d d
, ANS: D d
A Mongolian spot is a bluish black area of pigmentation that may appear over any part of the
d d d d d d d d d d d d d d d d d
exterior surface of the body. It is more commonly noted on the back and buttocks and most
d d d d d d d d d d d d d d d d
frequently is seen on infants whose ethnic origins are Mediterranean, Latin American, Asian, d d d d d d d d d d d d
or African. Lanugo is the fine, downy hair seen on a term newborn. A vascular nevus,
d d d d d d d d d d d d d d d
commonly called a strawberry mark, is a type of capillary hemangioma. A nevus flammeus, d d d d d d d d d d d d d
commonly called a port-wine stain, is most frequently found on the face. d d d d d d d d d d d
PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Diagnosis
d d d d d d d d d
MSC: Client Needs: Health Promotion and Maintenance
d d d d d d
6. While examining a newborn, the nurse notes uneven skinfolds on the buttocks and a click
d d d d d d d d d d d d d d d
when performing the Ortolani maneuver. The nurse recognizes these findings as a sign that
d d d d d d d d d d d d d
the newborn probably has:
d d d
a. polydactyly.
d
b. clubfoot.
d
c. hip dysplasia.
d d
d. webbing. - correct answer ANS: C
d d d d d d
The Ortolani maneuver is used to detect the presence of hip dysplasia. Polydactyly is the
d d d d d d d d d d d d d d
presence of extra digits. Clubfoot (talipes equinovarus) is a deformity in which the foot turns
d d d d d d d d d d d d d d
inward and is fixed in a plantar-flexion position. Webbing, or syndactyly, is a fusing of the
d d d d d d d d d d d d d d d
fingers or toes. d d
PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Nursing Process: Diagnosis
d d d d d d d d d
MSC: Client Needs: Health Promotion and Maintenance
d d d d d d
7. A new mother states that her infant must be cold because the baby's hands and feet are
d d d d d d d d d d d d d d d d d d
blue.
The nurse explains that this is a common and temporary condition called:
d d d d d d d d d d d
a. acrocyanosis.
d
b. erythema neonatorum.
d d
c. harlequin color.
d d
d. vernix caseosa. - correct answer ANS: A
d d d d d d d
Acrocyanosis, or the appearance of slightly cyanotic hands and feet, is caused by vasomotor d d d d d d d d d d d d d
instability, capillary stasis, and a high hemoglobin level. Acrocyanosis is normal and appears d d d d d d d d d d d d
intermittently over the first 7 to 10 days. Erythema toxicum (also called erythema d d d d d d d d d d d d
neonatorum) is a transient newborn rash that resembles flea bites. The harlequin sign is a d d d d d d d d d d d d d d
benign, transient color change in newborns. Half of the body is pale, and the other half is
d d d d d d d d d d d d d d d d
ruddy or bluish red with a line of demarcation. Vernix caseosa is a cheese-like, whitish
d d d d d d d d d d d d d d
substance that serves as a protective covering. d d d d d d
PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Nursing Process: Diagnosis
d d d d d d d d d
MSC: Client Needs: Health Promotion and Maintenance
d d d d d d
8. The nurse assessing a newborn knows that the most critical physiologic change required of
d d d d d d d d d d d d d d d
the
newborn is: d
a. closure of fetal shunts in the circulatory system.
d d d d d d d d
b. full function of the immune defense system at birth.
d d d d d d d d d
EXAM 2025 WITH CORRECT ANSWERS
Chapter 22: Physiologic and Behavioral Adaptations of the Newborn
d d d d d d d d
Perry: Maternal Child Nursing Care, 6th Edition
d d d d d d
MULTIPLE CHOICE d
1. A woman gave birth to a healthy 7-lb, 13-ounce infant girl. The nurse suggests that the
d d d d d d d d d d d d d d d d
woman place the infant to her breast within 15 minutes after birth. The nurse knows that
d d d d d d d d d d d d d d d
breastfeeding is effective during the first 30 minutes after birth because this is the:
d d d d d d d d d d d d d
a. transition period.
d d
b. first period of reactivity.
d d d d
c. organizational stage.
d d
d. second period of reactivity. - correct answer ANS: B
d d d d d d d d d
The first period of reactivity is the first phase of transition and lasts up to 30 minutes after
d d d d d d d d d d d d d d d d d
birth. The infant is highly alert during this phase. The transition period is the phase between
d d d d d d d d d d d d d d d
intrauterine and extrauterine existence. There is no such phase as the organizational stage.
d d d d d d d d d d d d d
The
second period of reactivity occurs roughly between 4 and 8 hours after birth, after a period of
d d d d d d d d d d d d d d d d
prolonged sleep. d
PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Planning
d d d d d d d d d
MSC: Client Needs: Health Promotion and Maintenance
d d d d d d
,2. Part of the health assessment of a newborn is observing the infant's breathing pattern. A
d d d d d d d d d d d d d d d
full-term newborn's breathing pattern is predominantly: d d d d d
a. abdominal with synchronous chest movements.
d d d d d
b. chest breathing with nasal flaring.
d d d d d
c. diaphragmatic with chest retraction.
d d d d
d. deep with a regular rhythm. - correct answer ANS: A
d d d d d d d d d d
In normal infant respiration the chest and abdomen rise synchronously, and breaths are
d d d d d d d d d d d d
shallow and irregular. Breathing with nasal flaring is a sign of respiratory distress.
d d d d d d d d d d d d
Diaphragmatic breathing with chest retraction is a sign of respiratory distress. Infant breaths d d d d d d d d d d d d
are not deep with a regular rhythm.
d d d d d d
PTS: 1 DIF: Cognitive Level: Comprehension
d d d d d
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
d d d d d d d d
3. While assessing the newborn, the nurse should be aware that the average expected apical
d d d d d d d d d d d d d d
pulse range of a full-term, quiet, alert newborn is:
d d d d d d d d
a. 80 to 100 beats/min.
d d d d
b. 100 to 120 beats/min.
d d d d
c. 120 to 160 beats/min.
d d d d
d. 150 to 180 beats/min. - correct answer ANS: C
d d d d d d d d d
The average infant heart rate while awake is 120 to 160 beats/min. The newborn's heart rate
d d d d d d d d d d d d d d d
may be about 85 to 100 beats/min while sleeping. The infant's heart rate typically is a bit
d d d d d d d d d d d d d d d d
higher when alert but quiet. A heart rate of 150 to 180 beats/min is typical when the infant
d d d d d d d d d d d d d d d d d
cries.
PTS: 1 DIF: Cognitive Level: Comprehension
d d d d d
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
d d d d d d d d d d
4. A newborn is placed under a radiant heat warmer, and the nurse evaluates the infant's body
d d d d d d d d d d d d d d d d
temperature every hour. Maintaining the newborn's body temperature is important for d d d d d d d d d d
preventing:
a. respiratory depression.
d d
b. cold stress.
d d
c. tachycardia.
d
d. vasoconstriction. - correct answer ANS: B
d d d d d d
Loss of heat must be controlled to protect the infant from the metabolic and physiologic
d d d d d d d d d d d d d d
effects of cold stress, and that is the primary reason for placing a newborn under a radiant heat
d d d d d d d d d d d d d d d d d
warmer. Cold stress results in an increased respiratory rate and vasoconstriction. d d d d d d d d d d
PTS: 1 DIF: Cognitive Level: Comprehension
d d d d d
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
d d d d d d d d
5. An African-American woman noticed some bruises on her newborn girl's buttocks. She
d d d d d d d d d d d d d
asks
the nurse who spanked her daughter. The nurse explains that these marks are called:
d d d d d d d d d d d d d
a. lanugo.
d
b. vascular nevi.
d d
c. nevus flammeus.
d d
d. Mongolian spots - correct answer .
d d d d d d
, ANS: D d
A Mongolian spot is a bluish black area of pigmentation that may appear over any part of the
d d d d d d d d d d d d d d d d d
exterior surface of the body. It is more commonly noted on the back and buttocks and most
d d d d d d d d d d d d d d d d
frequently is seen on infants whose ethnic origins are Mediterranean, Latin American, Asian, d d d d d d d d d d d d
or African. Lanugo is the fine, downy hair seen on a term newborn. A vascular nevus,
d d d d d d d d d d d d d d d
commonly called a strawberry mark, is a type of capillary hemangioma. A nevus flammeus, d d d d d d d d d d d d d
commonly called a port-wine stain, is most frequently found on the face. d d d d d d d d d d d
PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Nursing Process: Diagnosis
d d d d d d d d d
MSC: Client Needs: Health Promotion and Maintenance
d d d d d d
6. While examining a newborn, the nurse notes uneven skinfolds on the buttocks and a click
d d d d d d d d d d d d d d d
when performing the Ortolani maneuver. The nurse recognizes these findings as a sign that
d d d d d d d d d d d d d
the newborn probably has:
d d d
a. polydactyly.
d
b. clubfoot.
d
c. hip dysplasia.
d d
d. webbing. - correct answer ANS: C
d d d d d d
The Ortolani maneuver is used to detect the presence of hip dysplasia. Polydactyly is the
d d d d d d d d d d d d d d
presence of extra digits. Clubfoot (talipes equinovarus) is a deformity in which the foot turns
d d d d d d d d d d d d d d
inward and is fixed in a plantar-flexion position. Webbing, or syndactyly, is a fusing of the
d d d d d d d d d d d d d d d
fingers or toes. d d
PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Nursing Process: Diagnosis
d d d d d d d d d
MSC: Client Needs: Health Promotion and Maintenance
d d d d d d
7. A new mother states that her infant must be cold because the baby's hands and feet are
d d d d d d d d d d d d d d d d d d
blue.
The nurse explains that this is a common and temporary condition called:
d d d d d d d d d d d
a. acrocyanosis.
d
b. erythema neonatorum.
d d
c. harlequin color.
d d
d. vernix caseosa. - correct answer ANS: A
d d d d d d d
Acrocyanosis, or the appearance of slightly cyanotic hands and feet, is caused by vasomotor d d d d d d d d d d d d d
instability, capillary stasis, and a high hemoglobin level. Acrocyanosis is normal and appears d d d d d d d d d d d d
intermittently over the first 7 to 10 days. Erythema toxicum (also called erythema d d d d d d d d d d d d
neonatorum) is a transient newborn rash that resembles flea bites. The harlequin sign is a d d d d d d d d d d d d d d
benign, transient color change in newborns. Half of the body is pale, and the other half is
d d d d d d d d d d d d d d d d
ruddy or bluish red with a line of demarcation. Vernix caseosa is a cheese-like, whitish
d d d d d d d d d d d d d d
substance that serves as a protective covering. d d d d d d
PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Nursing Process: Diagnosis
d d d d d d d d d
MSC: Client Needs: Health Promotion and Maintenance
d d d d d d
8. The nurse assessing a newborn knows that the most critical physiologic change required of
d d d d d d d d d d d d d d d
the
newborn is: d
a. closure of fetal shunts in the circulatory system.
d d d d d d d d
b. full function of the immune defense system at birth.
d d d d d d d d d
