A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken. The nurse explains that this behavior indicates:

normal progression of behavior.

probable hypoglycemia.

physiological abnormality.

inadequate oxygenation.

Answer and Explanation

The Correct Answer is A

A. Newborns typically go through predictable behavioral states after birth. During the first period of reactivity, which lasts about 30–60 minutes after birth, the newborn is awake, alert, and active. This is followed by a period of sleep or decreased activity, which can last 2 to 4 hours. It is normal for the baby to be sleepy and difficult to awaken during this phase, especially around 2 hours of age.

B. Probable hypoglycemia could cause lethargy in a newborn, but it would typically be accompanied by other symptoms such as jitteriness, poor feeding, or abnormal vital signs. In a healthy 2-hour-old baby, sleepiness alone is not enough to suggest hypoglycemia.

C. Physiological abnormality is incorrect. There is no evidence of abnormality in a sleepy 2-hour-old newborn, as this is an expected part of the normal behavioral cycle after birth.

D. Inadequate oxygenation would likely present with signs such as cyanosis, abnormal respiratory rate, or poor perfusion, not just sleepiness.

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Correct Answer is B

Explanation

A. Difficulty in arousing suggests central nervous system depression, which can be a sign of magnesium toxicity. This is not a therapeutic effect and requires immediate assessment and possible discontinuation of the medication.
B. Deep tendon reflexes 2+ indicates normal neuromuscular function, which is consistent with therapeutic levels of magnesium sulfate. Loss of deep tendon reflexes is often the first sign of magnesium toxicity, so their presence at a normal level is reassuring.
C. Urinary output of 20 mL per hour is below the expected minimum (typically 30 mL/hour) and may suggest impaired renal function, which increases the risk of magnesium accumulation and toxicity.
D. Respiratory rate of 10 breaths/minute is lower than normal and may indicate respiratory depression, a serious sign of magnesium toxicity. A rate below 12 breaths/minute is concerning and not consistent with therapeutic dosing.

A. 7 B. 8 C. 5 D. 9

Correct Answer is D

Explanation

A. A score of 7 would be given if the infant’s heart rate was 100, but with less than optimal responses for color, muscle tone, and respiratory effort. However, this baby demonstrates strong responses in all categories.

B. A score of 8would indicate that the baby has no signs of cyanosis and perfect responses in all categories, but since the infant has blue hands, it scores slightly lower (1 point less for color).

C. A score of 5 would indicate more significant distress, with poor color, respiratory effort, and muscle tone. This infant is showing good signs of adaptation.

D. The Apgar score is calculated based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. The infant in the scenario has:Heart rate of 100 (score 2)Pink body and blue hands (score 1 for color—because the baby is not fully pink, indicating some cyanosis in the extremities)Active motion (score 2 for muscle tone)Strong lusty cry (score 2 for reflex irritability/responsiveness to stimuli)
Good respirations (score 2)Adding these scores (2 + 1 + 2 + 2 + 2), the total is 9.

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A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken. The nurse explains that this behavior indicates:

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Naxlex Comprehensive Predictor Exams

A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. The nurse determines that the medication is at a therapeutic level based on which finding?

Correct Answer is B

Explanation

The nurse is performing an Apgar score on a newborn at 5 minutes after birth. The infant has a heart rate of 100, pink body and blue hands, active motion, and a strong lust cry and respirations. What is the Apgar score that should be assigned to this infant?

Correct Answer is D

Explanation

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