A nurse is reinforcing teaching to a student nurse about Apgar scores in newborns.
Which of the following statements by the student demonstrates effective reinforcement?
An Apgar score evaluates how the newborn is transitioning to extrauterine life.
There are five components included in the Apgar score that are each given a number of 1 or 2.
It is unexpected for a newborn to receive a score of 1 for color.
Resuscitation interventions should not be started until after the 1-minute Apgar.
The Correct Answer is A
Choice A rationale
The Apgar score is a rapid assessment tool utilized at 1 and 5 minutes after birth to evaluate a newborn's physiological adjustment to extrauterine life. It assesses five critical parameters that reflect the newborn's cardiorespiratory and neurological status.
Choice B rationale
While there are five components in the Apgar score (Appearance, Pulse, Grimace, Activity, Respiration), each component can be scored 0, 1, or 2, not just 1 or 2. This scoring system allows for a more nuanced assessment of the newborn's condition.
Choice C rationale
It is not unexpected for a newborn to receive a score of 1 for color, especially at the 1-minute Apgar, as acrocyanosis (bluish discoloration of the hands and feet) is common due to immature peripheral circulation. This finding alone does not typically indicate significant distress.
Choice D rationale
Resuscitation interventions should be initiated based on the newborn's immediate clinical assessment, regardless of the Apgar score. If a newborn exhibits signs of distress, such as apnea or bradycardia, resuscitation should commence promptly without waiting for the 1-minute Apgar score.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
At the end of the first trimester, around 12-14 weeks gestation, the uterus is still relatively low in the pelvis. The symphysis pubis serves as a reliable anatomical landmark for locating the fundus of the uterus at this stage. Placing the Doppler just above this bony prominence allows for optimal transmission of sound waves to detect the fetal heart tones.
Choice B rationale
The right upper quadrant contains structures like the liver, gallbladder, and part of the colon. At the end of the first trimester, the uterus is not typically high enough to extend into this region. Therefore, attempting to locate fetal heart tones in this area would be ineffective and unlikely to yield a clear signal, as the fetus is not yet positioned there.
Choice C rationale
Just above the umbilicus is the general location for assessing fetal heart tones later in pregnancy, typically during the second and third trimesters when the uterus has significantly enlarged and risen out of the pelvis. At the end of the first trimester, the uterus is still too small and low for the fetal heart tones to be consistently heard at this location.
Choice D rationale
The left upper quadrant contains the stomach, spleen, and part of the colon. Similar to the right upper quadrant, the uterus is not positioned high enough in the first trimester to extend into this area. Therefore, attempting to locate fetal heart tones in the left upper quadrant would be inappropriate and unlikely to be successful.
Correct Answer is B
Explanation
Choice A rationale
Excessive dental caries and enlarged tonsils are more commonly associated with bulimia nervosa due to the repeated exposure of teeth to gastric acid from purging and chronic inflammation of the tonsils. Anorexia nervosa primarily involves severe caloric restriction, leading to different physiological adaptations.
Choice B rationale
Skeletal appearance with lanugo on arms is a classic physical finding supporting anorexia nervosa. The emaciated or skeletal appearance is due to severe caloric restriction and muscle wasting. Lanugo, fine downy hair, develops as the body attempts to conserve heat due to insufficient adipose tissue.
Choice C rationale
Irregular heart rate, specifically bradycardia, is common in anorexia nervosa due to metabolic slowdown. However, heavy menstruation (menorrhagia) is not typical; instead, amenorrhea (absence of menstruation) is a hallmark sign, resulting from hormonal imbalances due to malnutrition and low body fat.
Choice D rationale
Overweight with a puffy face is not indicative of anorexia nervosa. Anorexia nervosa is characterized by an extreme fear of gaining weight and a disturbed body image, leading to self-starvation and significant underweight. A puffy face can be associated with refeeding syndrome or specific medical conditions, not primary anorexia.
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