In determining the one minute Apgar score of a neonate, the nurse assesses a heart rate of 120 beats per minute and 44 respirations per minute. The neonate has flaccid muscle tone with slight flexion and slight resistance to straightening, a loud cry with stimulation, and acrocyanotic color. Which is the correct Apgar score for this neonate?
8.
10.
7.
9.
The Correct Answer is A
Rationale:
Heart rate: 120 bpm = 2
Respirations: 44/min with a loud cry = 2
Muscle tone: slight flexion with some resistance = 1
Reflex irritability: loud cry with stimulation = 2
Color: acrocyanosis (blue extremities) = 1
Total = 2 + 2 + 1 + 2 + 1 = 8
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Rationale:
A. Raise the head of the bed to Fowler's position: This immediately relieves orthopnea by improving lung expansion and reducing the work of breathing. Positioning is a first-line, non-invasive intervention to enhance respiratory comfort.
B. Provide oxygen per nasal cannula: Oxygen improves tissue oxygenation and prevents hypoxia progression. Although the saturation is borderline normal, oxygen can reduce respiratory effort in the context of fluid overload.
C. Administer a prescribed dose of furosemide: Diuretics treat the underlying cause—fluid overload related to possible heart failure. Removing excess fluid will decrease pulmonary congestion and peripheral edema.
D. Monitor urinary output: This evaluates the effectiveness of the diuretic therapy. Adequate urine output indicates that fluid is being removed and helps prevent worsening heart failure or electrolyte imbalance.
Correct Answer is B
Explanation
Rationale:
A. Observe wound drainage characteristics: Monitoring surgical wound drainage is not the immediate priority in the presence of a critically elevated blood glucose level. Hyperglycemia can impair wound healing, but signs of dehydration and fluid loss pose more immediate life-threatening concerns.
B. Assess for signs of fluid volume deficit: With a glucose level of 750 mg/dL, the client is at high risk for hyperosmolar hyperglycemic state (HHS), which causes severe dehydration due to osmotic diuresis. Assessing for fluid volume deficit is the priority to prevent hypovolemic shock and end-organ damage.
C. Determine when the client last ate: Knowing the time of last oral intake is useful in evaluating glucose trends, but it does not take precedence over assessing for the physiological effects of extreme hyperglycemia, such as dehydration and altered mental status.
D. Measure the level of acute pain: Pain assessment is essential in postoperative care, but it is not the top priority when blood glucose is dangerously high. Uncontrolled hyperglycemia can cause more rapid deterioration and must be assessed and managed first.
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