Ricci Chapter 18 UPDATED ACTUAL
Exam Questions and CORRECT 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 - CORRECT ANSWER - 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 - CORRECT
ANSWER - 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. - CORRECT ANSWER - 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? - CORRECT ANSWER - 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. - CORRECT ANSWER - Ans: B
Exam Questions and CORRECT 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 - CORRECT ANSWER - 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 - CORRECT
ANSWER - 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. - CORRECT ANSWER - 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? - CORRECT ANSWER - 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. - CORRECT ANSWER - Ans: B
