A newborn baby boy’s vital signs at 1 minute are as follows: Heart rate- 160 bpm, Respiratory effort - good, crying vigorously, Muscle tone - active movement, well flexed, Reflex irritability - cries with stimulation of soles of feet, Color

- body pink, feet and hands cyanotic.

What is the correct Apgar score for this newborn?

Answer and Explanation

The Correct Answer is D

Step 1 is: Calculate the Apgar score based on the given vital signs. The Apgar score is calculated based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color.

Step 2 is: Assign points for each criterion. For heart rate of 160 bpm, assign 2 points. For good, vigorous respiratory effort, assign 2 points. For active movement and well-flexed muscle tone, assign 2 points. For crying with stimulation of soles of feet (reflex irritability), assign 2 points. For body pink but feet and hands cyanotic (color), assign 1 point.

Step 3 is: Add up the points. 2 (heart rate) + 2 (respiratory effort) + 2 (muscle tone) + 2 (reflex irritability) + 1 (color) = 9 points. So, the correct Apgar score for this newborn is 9.

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Correct Answer is D

Explanation

Choice D rationale
The client is experiencing the first stage, latent phase of labor. This phase is characterized by contractions that are typically mild and irregular, occurring every 5-30 minutes and lasting about 30-45 seconds. The cervix dilates from 0 to 3 cm and effaces from 0% to 40%. The fetus descends into the pelvis, but is not yet engaged. The client may feel excited and anxious as labor begins.
Choice A rationale
The first stage, active phase of labor is characterized by regular, strong contractions occurring every 3-5 minutes and lasting about 40-70 seconds. The cervix dilates from 4 to 7 cm and effaces from 40% to 100%. The fetus descends and engages in the pelvis. The client may feel increased discomfort and a strong urge to bear down.
Choice B rationale
The first stage, transition phase of labor is characterized by intense contractions occurring every 2-3 minutes and lasting about 45-90 seconds. The cervix dilates from 8 to 10 cm and effaces from 100%. The fetus descends and engages in the pelvis. The client may feel overwhelmed, restless, and irritable.
Choice C rationale
The second stage of labor begins when the cervix is fully dilated and ends with the delivery of the baby. The contractions are strong, occurring every 2-3 minutes and lasting about 45-90 seconds. The client feels a strong urge to push during contractions.

A. “This test will indicate if your child has rheumatic fever.”. B. “This test will confirm if your child had a recent streptococcal infection.”. C. “This test will indicate if your child has a therapeutic blood level of an aminoglycoside.”. D. “This test will confirm if your child has immunity to streptococcal bacteria.”.

Correct Answer is B

Explanation

Choice A rationale
While an ASO titer test can be used in the diagnosis of rheumatic fever, it does not directly indicate if a child has rheumatic fever. Rheumatic fever is a complication that can occur after a streptococcal infection, and it involves multiple systems in the body, not just the presence of streptococcal antibodies.
Choice B rationale
An ASO titer test measures the antibodies produced by your body in response to a toxin known as streptolysin O, which is produced by group A Streptococcus (GAS) bacteria. Your body makes the antistreptolysin O antibodies when you have a strep infection caused by GAS bacteria. Therefore, a positive ASO titer test can confirm if your child had a recent streptococcal infection.
Choice C rationale
An ASO titer test does not measure the blood level of an aminoglycoside or any other therapeutic drug. Aminoglycosides are a class of antibiotics used to treat bacterial infections, and their levels in the blood are typically monitored with specific drug level tests, not an ASO titer.
Choice D rationale
An ASO titer test does not confirm if your child has immunity to streptococcal bacteria. The presence of ASO antibodies indicates a recent infection, but it does not provide information about the immune status or protection against future infections.

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is caring for a child who was admitted with suspected rheumatic fever. The provider prescribes an anti-streptolysin O (ASO) titer. The parent asks the nurse the purpose of the test. What should the nurse respond?

Correct Answer is B

Explanation

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