1 Exampromax - Stuvia US 2025/2026
Maternity Nclex questions with Detailed Verified Answers
(100% Correct Answers) /Already Graded 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
Typically, respirations in a 24-hour-old newborn are symmetric, slightly
Exampromax - Stuvia US
irregular, shallow, and unlabored at a rate of 30 to 60 breaths/minute. The
breathing pattern is primarily diaphragmatic. Nasal flaring, rates above 60
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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.
, 2 Exampromax - Stuvia US 2025/2026
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
Exampromax - Stuvia US
nearby in the bassinet is appropriate. Although a crib is the safest sleeping
Approved By:
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?
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 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?
, 3 Exampromax - Stuvia US 2025/2026
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 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.
Exampromax - Stuvia US
The parents of a newborn become concerned when they notice that their
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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
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.
, 4 Exampromax - Stuvia US 2025/2026
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
D) Risk for infection related to transition to extrauterine environment
Ans: A
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
Exampromax - Stuvia US
significantly below the accepted range of 97.7 to 99.7 degrees F. Therefore,
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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
Ans: D
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?
Maternity Nclex questions with Detailed Verified Answers
(100% Correct Answers) /Already Graded 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
Typically, respirations in a 24-hour-old newborn are symmetric, slightly
Exampromax - Stuvia US
irregular, shallow, and unlabored at a rate of 30 to 60 breaths/minute. The
breathing pattern is primarily diaphragmatic. Nasal flaring, rates above 60
Approved By:
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.
, 2 Exampromax - Stuvia US 2025/2026
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
Exampromax - Stuvia US
nearby in the bassinet is appropriate. Although a crib is the safest sleeping
Approved By:
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?
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 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?
, 3 Exampromax - Stuvia US 2025/2026
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 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.
Exampromax - Stuvia US
The parents of a newborn become concerned when they notice that their
Approved By:
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
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.
, 4 Exampromax - Stuvia US 2025/2026
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
D) Risk for infection related to transition to extrauterine environment
Ans: A
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
Exampromax - Stuvia US
significantly below the accepted range of 97.7 to 99.7 degrees F. Therefore,
Approved By:
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
Ans: D
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?
