Maternity Final Exam
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2025/2026 latest update
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,A woman gave birth to a healthy 7-pound, 13-ounce infant girl. The nurse suggests that the client place
the infant to her breast within 15 minutes after birth. The nurse is aware that the initiation of
breastfeeding is most effective during the first 30 minutes after birth. What is the correct term for this
phase of alertness?
a.Transition period
b.First period of reactivity
c.Organizational stage
d.Second period of reactivity - ✔✔answer ANS: B
The first period of reactivity is the first phase of transition and lasts up to 30 minutes after birth. The
infant is highly alert during this phase. The transition period is the phase between intrauterine and
extrauterine existence. An organizational stage is not a valid stage. The second period of reactivity
occurs approximately between 4 and 8 hours after birth, after a period of sleep.
Part of the health assessment of a newborn is observing the infant's breathing pattern. What is the
predominate pattern of newborn's breathing?
a.Abdominal with synchronous chest movements
b.Chest breathing with nasal flaring
,c.Diaphragmatic with chest retraction
d.Deep with a regular rhythm - ✔✔answer ANS: A
In a normal infant respiration, the chest and abdomen synchronously rise and infant breaths are shallow
and irregular. Breathing with nasal flaring is a sign of respiratory distress. Diaphragmatic breathing with
chest retraction is also a sign of respiratory distress.
The nurse is assessing a full term, quiet, and alert newborn. What is the average expected apical pulse
range (in beats per minute)?
a.80 to 100
b.100 to 120
c.120 to 160
d.150 to 180 - ✔✔answer ANS: C
The average infant heart rate while awake is 120 to 160 beats per minute. The newborn's heart rate may
be approximately 85 to 100 beats per minute while sleeping and typically a little higher than 100 to 120
beats per minute when alert but quiet. A heart rate of 150 to 180 beats per minute is typical when the
infant cries.
A newborn is placed under a radiant heat warmer. The nurse understands that thermoregulation
presents a problem for the newborn. What is the rationale for this difficulty?
,a.The renal function of a newborn is not fully developed, and heat is lost in the urine.
b.The small body surface area of a newborn favors more rapid heat loss than does an adult's body
surface area.
c.Newborns have a relatively thin layer of subcutaneous fat that provides poor insulation.
d.Their normal flexed posture favors heat loss through perspiration. - ✔✔answer ANS: C
The newborn has little thermal insulation. Furthermore, the blood vessels are closer to the surface of
the skin. Changes in environmental temperature alter the temperature of the blood, thereby influencing
temperature regulation centers in the hypothalamus. Heat loss does not occur through urination.
Newborns have a higher body surface-to-weight ratio than adults. The flexed position of the newborn
helps guard against heat loss, because it diminishes the amount of body surface exposed to the
environment.
An African-American woman noticed some bruises on her newborn daughter's buttocks. The client asks
the nurse what causes these. How would the nurse best explain this integumentary finding to the client?
a.Lanugo
b.Vascular nevus
c.Nevus flammeus
,d.Mongolian spot - ✔✔answer ANS: D
A Mongolian spot is a bluish-black area of pigmentation that may appear over any part of the exterior
surface of the infant's body and is more commonly noted on the back and buttocks and most frequently
observed on infants whose ethnic origins are Mediterranean, Latin American, Asian, or African. Lanugo
is the fine, downy hair observed on a term newborn. A vascular nevus, commonly called a strawberry
mark, is a type of capillary hemangioma. A nevus flammeus, commonly called a port wine stain, is most
frequently found on the face.
While examining a newborn, the nurse notes uneven skinfolds on the buttocks and a clunk when
performing the Ortolani maneuver. These findings are likely indicative of what?
a.Polydactyly
b.Clubfoot
c.Hip dysplasia
d.Webbing - ✔✔answer ANS: C
The Ortolani maneuver is used to detect the presence of hip dysplasia. Polydactyly is the presence of
extra digits. Clubfoot (talipes equinovarus) is a deformity in which the foot turns inward and is fixed in a
plantar-flexion position. Webbing, or syndactyly, is a fusing of the fingers or toes.
A new mother states that her infant must be cold because the baby's hands and feet are blue. This
common and temporary condition is called what?
, a.Acrocyanosis
b.Erythema toxicum neonatorum
c.Harlequin sign
d.Vernix caseosa - ✔✔answer ANS: A
Acrocyanosis, or the appearance of slightly cyanotic hands and feet, is caused by vasomotor instability,
capillary stasis, and a high hemoglobin level. Acrocyanosis is normal and intermittently appears over the
first 7 to 10 days after childbirth. Erythema toxicum neonatorum (also called erythema neonatorum) is a
transient newborn rash that resembles flea bites. The harlequin sign is a benign, transient color change
in newborns. One half of the body is pale, and the other one half is ruddy or bluish-red with a line of
demarcation. Vernix caseosa is a cheeselike, whitish substance that serves as a protective covering for
the newborn.
What is the most critical physiologic change required of the newborn after birth?
a.Closure of fetal shunts in the circulatory system
b.Full function of the immune defense system
c.Maintenance of a stable temperature
d.Initiation and maintenance of respirations - ✔✔answer ANS: D