Ricci Chapter 18 - Test Bank - 4th
Edition, Ricci Chapter 17 - Test Bank -
4th Edition, Ricci Chapter 16 - Test
Bank - 4th Edition Questions with
Correct Solutions.
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 - Answer 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 - Answer 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. - Answer 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? - Answer 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 - Answer 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. - Answer 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. - Answer 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.
8. While making rounds in the nursery, the nurse sees a 6-hour-old baby girl gagging and turning
bluish. What would the nurse do first?
A. Alert the primary care provider stat, and turn the newborn to her right side.
B. Administer oxygen via facial mask by positive pressure.
C. Lower the newborn's head to stimulate crying.
D. Aspirate the oral and nasal pharynx with a bulb syringe. - Answer Answer: D
Rationale: The nurse's first action would be to suction the oral and nasal pharynx with a bulb
syringe to maintain airway patency. Turning the newborn to her right side will not alleviate the
, blockage due to secretions. Administering oxygen via positive pressure is not indicated at this
time. Lowering the newborn's head would be inappropriate.
9. While performing a physical assessment of a newborn boy, the nurse notes diffuse edema of
the soft tissues of his scalp that crosses suture lines. The nurse documents this finding as:
A. molding.
B. microcephaly.
C. caput succedaneum.
D. cephalhematoma. - Answer Answer: C
Rationale: Caput succedaneum is localized edema on the scalp, a poorly demarcated soft tissue
swelling that crosses the suture lines. Molding refers to the elongated shape of the fetal head as
it
accommodates to the passage through the birth canal. Microcephaly refers to a head
circumference that is 2 standard deviations below average or less than 10% of normal
parameters
for gestational age. Cephalhematoma is a localized effusion of blood beneath the periosteum of
the skull.
10. Assessment of a newborn reveals uneven gluteal (buttocks) skin creases and a "clunk" when
the Ortolani maneuver is performed. What would the nurse suspect?
A. slipping of the periosteal joint
B. developmental hip dysplasia
C. normal newborn variation
D. overriding of the pelvic bone - Answer Answer: B
Rationale: A "clunk" indicates the femoral head hitting the acetabulum as the head reenters the
area. This, along with uneven gluteal creases, suggests developmental hip dysplasia. These
findings are not a normal variation and are not associated with slipping of the periosteal joint or
overriding of the pelvic bone.
11. A nurse is assessing a newborn's reflexes. The nurse strokes the lateral sole of the newborn's
foot from the heel to the ball of the foot to elicit which reflex?
A. Babinski
B. tonic neck
C. stepping
D. plantar grasp - Answer Answer: A
Edition, Ricci Chapter 17 - Test Bank -
4th Edition, Ricci Chapter 16 - Test
Bank - 4th Edition Questions with
Correct Solutions.
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 - Answer 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 - Answer 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. - Answer 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? - Answer 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 - Answer 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. - Answer 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. - Answer 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.
8. While making rounds in the nursery, the nurse sees a 6-hour-old baby girl gagging and turning
bluish. What would the nurse do first?
A. Alert the primary care provider stat, and turn the newborn to her right side.
B. Administer oxygen via facial mask by positive pressure.
C. Lower the newborn's head to stimulate crying.
D. Aspirate the oral and nasal pharynx with a bulb syringe. - Answer Answer: D
Rationale: The nurse's first action would be to suction the oral and nasal pharynx with a bulb
syringe to maintain airway patency. Turning the newborn to her right side will not alleviate the
, blockage due to secretions. Administering oxygen via positive pressure is not indicated at this
time. Lowering the newborn's head would be inappropriate.
9. While performing a physical assessment of a newborn boy, the nurse notes diffuse edema of
the soft tissues of his scalp that crosses suture lines. The nurse documents this finding as:
A. molding.
B. microcephaly.
C. caput succedaneum.
D. cephalhematoma. - Answer Answer: C
Rationale: Caput succedaneum is localized edema on the scalp, a poorly demarcated soft tissue
swelling that crosses the suture lines. Molding refers to the elongated shape of the fetal head as
it
accommodates to the passage through the birth canal. Microcephaly refers to a head
circumference that is 2 standard deviations below average or less than 10% of normal
parameters
for gestational age. Cephalhematoma is a localized effusion of blood beneath the periosteum of
the skull.
10. Assessment of a newborn reveals uneven gluteal (buttocks) skin creases and a "clunk" when
the Ortolani maneuver is performed. What would the nurse suspect?
A. slipping of the periosteal joint
B. developmental hip dysplasia
C. normal newborn variation
D. overriding of the pelvic bone - Answer Answer: B
Rationale: A "clunk" indicates the femoral head hitting the acetabulum as the head reenters the
area. This, along with uneven gluteal creases, suggests developmental hip dysplasia. These
findings are not a normal variation and are not associated with slipping of the periosteal joint or
overriding of the pelvic bone.
11. A nurse is assessing a newborn's reflexes. The nurse strokes the lateral sole of the newborn's
foot from the heel to the ball of the foot to elicit which reflex?
A. Babinski
B. tonic neck
C. stepping
D. plantar grasp - Answer Answer: A
