A nurse is teaching a class on Apgar scoring to nursing students. Which statement by a student indicates a need for further teaching

“If a newborn has a heart rate below 100 beats per minute, he will receive one point for heart rate.”

“If a newborn has acrocyanosis, he will receive one point for color.”

“If a newborn has active motion of extremities, he will receive two points for muscle tone.”

“If a newborn has a vigorous cry when stimulated, he will receive two points for reflex irritability.”.

Answer and Explanation

The Correct Answer is B

This is wrong because acrocyanosis means that the body is pink but the extremities are blue, which indicates poor circulation. A normal Apgar score for color is two points, which means that the baby is pink all over.

Choice A is correct because a heart rate below 100 beats per minute is considered moderately abnormal and receives one point.

Choice C is correct because active motion of extremities indicates good muscle tone and receives two points.

Choice D is correct because a vigorous cry when stimulated indicates good reflex irritability and receives two points.

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Correct Answer is A

Explanation

Apply a thin ribbon of ointment along the inner canthus of each eye.This is the recommended method for administering erythromycin ointment to a newborn’s eyes as prophylaxis for gonorrhea and chlamydia infections.The ointment should be applied into the conjunctival sac to avoid accidental injury to the eye.

ChoiceBis wrong because the eyes should not be wiped off after applying the ointment.The ointment will gradually dissolve and disperse over the eye surface.

ChoiceCis wrong because the medication is an ointment, not a drop.

A drop would not provide adequate coverage of the eye and would be more likely to cause irritation

A. Carbon monoxide poisoning B. Meniere’s disease C. Migraine D. Benign paroxysmal positional vertigo.

Correct Answer is A

Explanation

Carbon monoxide poisoning.

This is because the client reports having a headache and vertigo after turning on his furnace for the first time this season.These are common symptoms of carbon monoxide poisoning, which can occur when carbon monoxide, a colorless and odorless gas, builds up in the blood due to exposure to combustion fumes.

The furnace may have been a source of carbon monoxide if it was not well vented or maintained.

The other statements are wrong because:

Meniere’s disease is a disorder of the inner ear that causes vertigo, hearing loss, tinnitus and ear fullness. It is not related to carbon monoxide exposure or furnace use.

Migraine is a type of headache that causes throbbing pain, nausea, sensitivity to light and sound, and sometimes visual disturbances. It is not caused by carbon monoxide exposure or furnace use, but by genetic and environmental factors.

Benign paroxysmal positional vertigo (BPPV) is a condition that causes brief episodes of vertigo triggered by changes in head position. It is caused by tiny crystals in the inner ear that become dislodged and stimulate the balance sensors. It is not related to carbon monoxide exposure or furnace use.

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A nurse is teaching a class on Apgar scoring to nursing students. Which statement by a student indicates a need for further teaching

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer erythromycin ointment to a newborn’s eyes as prophylaxis for gonorrhea and chlamydia infections. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who reports that he has a headache and vertigo after turning on his furnace for the first time this season. The nurse suspect which of the following?

Correct Answer is A

Explanation

Select all that apply. A nurse is providing comfort measures to a newborn during an assessment. What non-pharmacological interventions can the nurse use to soothe the newborn?

A nurse is supporting bonding and attachment between parents and their newborn. What intervention should the nurse implement to promote skin-to-skin contact?

A nurse is performing the physical maturity test on a newborn using the New Ballard Scale. What characteristic would the nurse assess?

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A nurse is performing a head-to-toe assessment of a newborn. What finding should alert the nurse to a potential problem with the newborn’s fontanelles?

A nurse palpates an infant’s anterior fontanelle and notes that it feels soft and flat when lying down, but slightly elevated when sitting up or crying. What should be included in documentation?

A nurse is caring for a newborn who has an Apgar score of 8 at one minute after birth and an Apgar score of 10 at five minutes after birth. Which statement best describes this newborn’s condition?

A nurse is assessing a newborn's gestational age using the New Ballard Scale. Which of the following signs would indicate prematurity?