RICCI CHAPTER 18 - TEST BANK - 4TH
EDITION, RICCI CHAPTER 17 - TEST
BANK - 4TH EDITION, RICCI CHAPTER
16 - TEST BANK - 4TH EDITION
1. Prior to discharging a 24-hour-old newborn, the nurse assesses the newborn's
respiratory
status. What would the nurse expect to assess?
A. respiratory rate 45 breaths/minute, irregular
B. costal breathing pattern
C. nasal flaring, rate 65 breaths/minute
D. crackles on auscultation - Correct Answers -Answer: A
Rationale: 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.
2. 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 Answers -
Answer: C
Rationale: Breastfeeding 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.
3. When making a home visit, the nurse observes a newborn sleeping on his back in a
bassinet.
In one corner of the bassinet is some soft bedding material, and at the other end is a
bulb syringe.
The nurse determines that the mother needs additional teaching for which reason?
A. The newborn should not be sleeping on his back.
B. Soft bedding material 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 Answers -Answer: B
Rationale: 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.
4. Assessment of a newborn reveals a heart rate of 180 beats per 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? - Correct Answers -Answer: A
Rationale: The typical heart rate of a newborn ranges from 110 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.
5. When assessing a newborn 1 hour after birth, the nurse measures an axillary
temperature of
95.8° F (35.4° C), an apical pulse of 114 beats per minute, and a respiratory rate of 60
breaths
per minute. The nurse would identify which area as the priority?
A. hypothermia
B. impaired parenting
C. deficient fluid volume
D. risk for infection - Correct Answers -Answer: A
,Rationale: The newborn's heart rate is slightly below the accepted range of 120 to 160
beats per
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 significantly below the accepted range
of 97.7 to
99.7? (36.5 to 37.6?). Therefore, the priority problem area is hypothermia. There is no
information to suggest impaired parenting. Additional information is needed to
determine if there
is deficient fluid volume or a risk for infection.
6. 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. - Correct Answers -Answer: D
Rationale: 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.
7. During a physical assessment of a newborn, the nurse observes bluish markings
across the
newborn's lower back. The nurse interprets this finding as:
A. milia.
B. Mongolian spots.
C. stork bites.
D. birth trauma. - Correct Answers -Answer: B
Rationale: Mongolian spots are blue or purple splotches that appear on the lower back
and
buttocks of newborns. Milia are unopened sebaceous glands frequently found on a
newborn's
nose. Stork bites are superficial vascular areas found on the nape of the neck and
eyelids and
between the eyes and upper lip. Birth trauma would be manifested by bruising, swelling,
and
possible deformity.
26. A postpartum woman who is bottle-feeding her newborn asks the nurse, "About how
much
should my newborn drink at each feeding?" The nurse responds by saying that to feel
satisfied,
the newborn needs which amount at each feeding?
, A. 1 to 2 ounces
B. 2 to 4 ounces
C. 4 to 6 ounces
D. 6 to 8 ounces - Correct Answers -Answer: B
Rationale: Newborns need about 108 cal/kg or approximately 650 cal/day (Dudek,
2010).
Therefore, a newborn will need to 2 to 4 ounces to feel satisfied at each feeding.
27. A nurse is observing a postpartum woman and her partner interact with the their
newborn.
The nurse determines that the parents are developing parental attachment with their
newborn
when they demonstrate which behavior? Select all that apply.
A. frequently ask for the newborn to be taken from the room
B. identify common features between themselves and the newborn
C. refer to the newborn as having a monkey-face
D. make direct eye contact with the newborn
E. refrain from checking out the newborn's features - Correct Answers -Answer: B, D
Rationale: Positive behaviors that indicate attachment include identifying common
features and
making direct eye contact with the newborn. Asking for the newborn to be taken out of
the room, referring to the newborn as having a monkey-face, and refraining from
checking out the
newborn's features are negative attachment behaviors.
28. A nurse is conducting a class for pregnant women who are in their third trimester.
The nurse
is reviewing information about the emotional changes that occur in the postpartum
period,
including postpartum blues and postpartum depression. After reviewing information
about
postpartum blues, the group demonstrates understanding when they make which
statement about
this condition?
A. "Postpartum blues is a long-term emotional disturbance."
B. "Getting some outside help for housework can lessen feelings of being
overwhelmed."
C. "The mother loses contact with reality."
D. "Extended psychotherapy is needed for treatment." - Correct Answers -Answer: B
Rationale: Postpartum blues require no formal treatment other than support and
reassurance
because they do not usually interfere with the woman's ability to function and care for
her infant.
Nurses can ease a mother's distress by encouraging her to vent her feelings and by
demonstrating
EDITION, RICCI CHAPTER 17 - TEST
BANK - 4TH EDITION, RICCI CHAPTER
16 - TEST BANK - 4TH EDITION
1. Prior to discharging a 24-hour-old newborn, the nurse assesses the newborn's
respiratory
status. What would the nurse expect to assess?
A. respiratory rate 45 breaths/minute, irregular
B. costal breathing pattern
C. nasal flaring, rate 65 breaths/minute
D. crackles on auscultation - Correct Answers -Answer: A
Rationale: 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.
2. 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 Answers -
Answer: C
Rationale: Breastfeeding 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.
3. When making a home visit, the nurse observes a newborn sleeping on his back in a
bassinet.
In one corner of the bassinet is some soft bedding material, and at the other end is a
bulb syringe.
The nurse determines that the mother needs additional teaching for which reason?
A. The newborn should not be sleeping on his back.
B. Soft bedding material 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 Answers -Answer: B
Rationale: 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.
4. Assessment of a newborn reveals a heart rate of 180 beats per 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? - Correct Answers -Answer: A
Rationale: The typical heart rate of a newborn ranges from 110 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.
5. When assessing a newborn 1 hour after birth, the nurse measures an axillary
temperature of
95.8° F (35.4° C), an apical pulse of 114 beats per minute, and a respiratory rate of 60
breaths
per minute. The nurse would identify which area as the priority?
A. hypothermia
B. impaired parenting
C. deficient fluid volume
D. risk for infection - Correct Answers -Answer: A
,Rationale: The newborn's heart rate is slightly below the accepted range of 120 to 160
beats per
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 significantly below the accepted range
of 97.7 to
99.7? (36.5 to 37.6?). Therefore, the priority problem area is hypothermia. There is no
information to suggest impaired parenting. Additional information is needed to
determine if there
is deficient fluid volume or a risk for infection.
6. 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. - Correct Answers -Answer: D
Rationale: 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.
7. During a physical assessment of a newborn, the nurse observes bluish markings
across the
newborn's lower back. The nurse interprets this finding as:
A. milia.
B. Mongolian spots.
C. stork bites.
D. birth trauma. - Correct Answers -Answer: B
Rationale: Mongolian spots are blue or purple splotches that appear on the lower back
and
buttocks of newborns. Milia are unopened sebaceous glands frequently found on a
newborn's
nose. Stork bites are superficial vascular areas found on the nape of the neck and
eyelids and
between the eyes and upper lip. Birth trauma would be manifested by bruising, swelling,
and
possible deformity.
26. A postpartum woman who is bottle-feeding her newborn asks the nurse, "About how
much
should my newborn drink at each feeding?" The nurse responds by saying that to feel
satisfied,
the newborn needs which amount at each feeding?
, A. 1 to 2 ounces
B. 2 to 4 ounces
C. 4 to 6 ounces
D. 6 to 8 ounces - Correct Answers -Answer: B
Rationale: Newborns need about 108 cal/kg or approximately 650 cal/day (Dudek,
2010).
Therefore, a newborn will need to 2 to 4 ounces to feel satisfied at each feeding.
27. A nurse is observing a postpartum woman and her partner interact with the their
newborn.
The nurse determines that the parents are developing parental attachment with their
newborn
when they demonstrate which behavior? Select all that apply.
A. frequently ask for the newborn to be taken from the room
B. identify common features between themselves and the newborn
C. refer to the newborn as having a monkey-face
D. make direct eye contact with the newborn
E. refrain from checking out the newborn's features - Correct Answers -Answer: B, D
Rationale: Positive behaviors that indicate attachment include identifying common
features and
making direct eye contact with the newborn. Asking for the newborn to be taken out of
the room, referring to the newborn as having a monkey-face, and refraining from
checking out the
newborn's features are negative attachment behaviors.
28. A nurse is conducting a class for pregnant women who are in their third trimester.
The nurse
is reviewing information about the emotional changes that occur in the postpartum
period,
including postpartum blues and postpartum depression. After reviewing information
about
postpartum blues, the group demonstrates understanding when they make which
statement about
this condition?
A. "Postpartum blues is a long-term emotional disturbance."
B. "Getting some outside help for housework can lessen feelings of being
overwhelmed."
C. "The mother loses contact with reality."
D. "Extended psychotherapy is needed for treatment." - Correct Answers -Answer: B
Rationale: Postpartum blues require no formal treatment other than support and
reassurance
because they do not usually interfere with the woman's ability to function and care for
her infant.
Nurses can ease a mother's distress by encouraging her to vent her feelings and by
demonstrating
