Ricci Chapter 18 Exam Questions With
All Correct Detailed Answers Verified
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 birth weight?
D) Is acrocyanosis present? - Ans: A
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
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 birth
weight 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° C. 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° C (97.7 to 99.7° 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
Feedback:
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° 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
All Correct Detailed Answers Verified
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 birth weight?
D) Is acrocyanosis present? - Ans: A
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
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 birth
weight 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° C. 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° C (97.7 to 99.7° 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
Feedback:
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° 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
