Maternity NCLEX Questions| Newborn assessment,
tests for fetal well-being- Qs & As
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. Correct 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 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?
, Maternity NCLEX Questions| Newborn assessment,
tests for fetal well-being- Qs & As
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 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?
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. Correct Ans-B
, Maternity NCLEX Questions| Newborn assessment,
tests for fetal well-being- Qs & As
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.
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. Correct 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
, Maternity NCLEX Questions| Newborn assessment,
tests for fetal well-being- Qs & As
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.
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 Correct 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 significantly below the accepted range of 97.7 to 99.7
degrees F. Therefore, 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.
tests for fetal well-being- Qs & As
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. Correct 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 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?
, Maternity NCLEX Questions| Newborn assessment,
tests for fetal well-being- Qs & As
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 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?
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. Correct Ans-B
, Maternity NCLEX Questions| Newborn assessment,
tests for fetal well-being- Qs & As
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.
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. Correct 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
, Maternity NCLEX Questions| Newborn assessment,
tests for fetal well-being- Qs & As
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.
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 Correct 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 significantly below the accepted range of 97.7 to 99.7
degrees F. Therefore, 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.
