1. A woman gave birth to a healthy 7-pound, 13-ounce infant girl. The nurse suggests that the
woman place the infant to her breast within 15 minutes
... [Show More] after birth. The nurse knows that
breastfeeding is effective during the first 30 minutes after birth because this is the:
a. Transition period. c. Organizational stage.
b. First period of reactivity. d. Second period of reactivity.
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. There is no such phase as the organizational stage. The
second period of reactivity occurs roughly between 4 and 8 hours after birth, after a period of
prolonged sleep.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 556
OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance
2. Part of the health assessment of a newborn is observing the infant’s breathing pattern. A
full-term newborn’s breathing pattern is predominantly:
a. Abdominal with synchronous chest movements.
b. Chest breathing with nasal flaring.
c. Diaphragmatic with chest retraction.
d. Deep with a regular rhythm.
ANS: A
In normal infant respiration the chest and abdomen rise synchronously, and breaths are
shallow and irregular. Breathing with nasal flaring is a sign of respiratory distress.
Diaphragmatic breathing with chest retraction is a sign of respiratory distress. Infant breaths
are not deep with a regular rhythm.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 557
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
3. While assessing the newborn, the nurse should be aware that the average expected apical
pulse range of a full-term, quiet, alert newborn is:
a. 80 to 100 beats/min. c. 120 to 160 beats/min.
b. 100 to 120 beats/min. d. 150 to 180 beats/min.
ANS: C
The average infant heart rate while awake is 120 to 160 beats/min. The newborn’s heart rate
may be about 85 to 100 beats/min while sleeping. The infant’s heart rate typically is a bit
higher when alert but quiet. A heart rate of 150 to 180 beats/min is typical when the infant
cries.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 559
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
TEST BANK FOR MATERNAL CHILD NURSING CARE 5TH EDITION BY PERRY
NURSINGTB.COM
N U R S I N G T B . C O M
4. A newborn is placed under a radiant heat warmer, and the nurse evaluates the infant’s body
temperature every hour. Maintaining the newborn’s body temperature is important for
preventing:
a. Respiratory depression. c. Tachycardia.
b. Cold stress. d. Vasoconstriction.
ANS: B
Loss of heat must be controlled to protect the infant from the metabolic and physiologic
effects of cold stress, and that is the primary reason for placing a newborn under a radiant heat
warmer. Cold stress results in an increased respiratory rate and vasoconstriction.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 561
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
5. An African-American woman noticed some bruises on her newborn girl’s buttocks. She asks
the nurse who spank [Show Less]