WEST VIRGINIA UNIVERSIRTY-WV26506
Maternity Nclex questions with 100% 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 - ✔️✔️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
1
,©PREP4EXAMS@2024/2025 [ REAL-EXAM-DUMPS] Monday, August 5, 2024 1: 54 PM
WEST VIRGINIA UNIVERSIRTY-WV26506
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 - ✔️✔️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.
2
,©PREP4EXAMS@2024/2025 [ REAL-EXAM-DUMPS] Monday, August 5, 2024 1: 54 PM
WEST VIRGINIA UNIVERSIRTY-WV26506
D) This newborn should be sleeping in a crib. - ✔️✔️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? - ✔️✔️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.
3
, ©PREP4EXAMS@2024/2025 [ REAL-EXAM-DUMPS] Monday, August 5, 2024 1: 54 PM
WEST VIRGINIA UNIVERSIRTY-WV26506
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. - ✔️✔️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.
4