A nurse assesses a baby boy at 1 minute after birth and notes a heart rate of 90 beats per minute, some flexion of extremities, a weak cry, a prompt response to stimuli and a pink body but blue extremities. Which Apgar score does the nurse calculate based on the assessment?

Answer and Explanation

The Correct Answer is D

A. 4 is incorrect because the infant demonstrates more than minimal findings across several Apgar components, resulting in a higher score than 4.

B. 7 is incorrect because a score of 7 would require stronger respiratory effort (good cry) or a heart rate above 100 beats per minute, which are not present in this assessment.

C. 5 is incorrect because the infant earns more points based on reflex irritability and overall appearance, making the score higher than 5.

D. 6 is correct because the Apgar score is calculated as follows:

Heart rate of 90 beats per minute = 1 point
Weak cry = 1 point
Some flexion of extremities = 1 point
Prompt response to stimuli = 2 points
Pink body with blue extremities (acrocyanosis) = 1 point

The total Apgar score at 1 minute is 6.

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Correct Answer is A

Explanation

A. Chorionic villus sampling (CVS) is typically performed between 10 and 13 weeks of gestation. It involves obtaining a small sample of placental tissue (chorionic villi) to test for chromosomal abnormalities, genetic disorders, and certain metabolic conditions. Performing the procedure within this timeframe allows for early detection of fetal abnormalities, which gives the parents more options for pregnancy management.

B. By 18 weeks of gestation, CVS is no longer indicated, as amniocentesis becomes the preferred procedure for prenatal genetic testing at mid-pregnancy. Performing CVS this late would increase the risk of complications without providing additional benefit.

C. At 6 weeks, the placenta is not sufficiently developed to obtain an adequate sample of chorionic villi. Attempting CVS this early carries a higher risk of procedure failure and complications, including miscarriage.

D. At 4 weeks, the embryo is too small and placental development is insufficient for CVS. Genetic testing is not feasible at this stage, and attempting it would be unsafe.

A. Preterm labor occurs when the cervix remains closed. B. A woman with symptoms can wait several days before contacting the primary caregiver. C. The client can ambulate for 2 hours. D. Diagnosis of preterm labor is based on gestational age, uterine activity, and progressive cervical change.

Correct Answer is D

Explanation

A. Preterm labor does not occur when the cervix remains closed. It is characterized by regular uterine contractions accompanied by progressive cervical change, including effacement and dilation before 37 weeks of gestation. A closed cervix without dilation or effacement is not indicative of preterm labor, making this statement incorrect.

B. Waiting several days before contacting the provider is dangerous and inappropriate. Preterm labor can progress rapidly, potentially leading to preterm birth and neonatal complications. Clients should contact their healthcare provider immediately if they experience symptoms such as contractions, pelvic pressure, or changes in vaginal discharge.

C. Ambulating for 2 hours is not recommended in the context of suspected preterm labor. In fact, activity can sometimes exacerbate uterine contractions. Bed rest or reduced activity may be advised while the client awaits evaluation, depending on provider recommendations.

D. Diagnosis of preterm labor is based on gestational age, uterine activity, and progressive cervical change. This means labor occurring before 37 weeks, regular contractions (typically four or more in 20 minutes or eight or more in 60 minutes), and measurable cervical changes such as effacement of 80% or dilation of 1 cm or more. This statement accurately reflects the clinical criteria used to identify preterm labor and is the most important information for the nurse to understand and communicate to the client.

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A nurse assesses a baby boy at 1 minute after birth and notes a heart rate of 90 beats per minute, some flexion of extremities, a weak cry, a prompt response to stimuli and a pink body but blue extremities. Which Apgar score does the nurse calculate based on the assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While working with the pregnant client in her first trimester, what information does the nurse provide regarding when chorionic villus sampling (CVS) can be performed (in weeks of gestation)?

Correct Answer is A

Explanation

The nurse is performing an assessment on a client who thinks she may be experiencing preterm labor. Which information is most important for the nurse to understand and share with the client?

Correct Answer is D

Explanation

A nurse is assessing a client that delivered 1 hour ago. Which of the following findings is an early indication of hypovolemic shock?

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