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 B
Explanation
Rationale:
A. Before changing assignments, determine which staff members have fitted particulate filter masks: This option suggests rearranging assignments based on respirator fit, but a particulate filter mask (like an N95) is not required for droplet precautions. The focus should be on educating the UAP rather than altering assignments unnecessarily.
B. Instruct the UAP that a standard face mask is sufficient to be able to provide care for the assigned client: Droplet precautions require a standard surgical mask, not a particulate filter mask. The nurse should clarify this with the UAP to ensure proper precautions are followed without unnecessary changes or delays in care.
C. Advise the UAP to wear a standard face mask to obtain vital signs, and then get fitted for a filter mask before providing personal care: This adds unnecessary steps. For droplet precautions, a surgical mask is sufficient for all aspects of client care. There's no need to delay care or obtain a filter mask fitting.
D. Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client: This is not necessary for droplet precautions, as it reflects confusion with airborne precautions (e.g., for tuberculosis). The nurse should correct the misunderstanding rather than escalate it.
Correct Answer is C
Explanation
Rationale:
A. Go to the emergency department and complete assigned tasks: UAPs should remain on their assigned units unless directed otherwise by leadership. Relocating without orders could compromise continuity and safety in their current area.
B. Shut all doors to client rooms on the unit in case a fire erupts: There is no immediate threat of fire. This may increase client anxiety or hinder necessary observation in a power outage. Fire protocols are separate from internal disaster procedures unless a fire is confirmed.
C. Tell all their assigned clients to stay in their rooms: This maintains order and safety during a chaotic event. It prevents unnecessary movement in darkened or unfamiliar areas and reduces the risk of injury in the absence of full power.
D. Offer to assist in the intensive care unit with clients ventilator-dependent: UAPs are not qualified to assist with critical care clients, especially ventilator-dependent ones. They should remain within their competency and scope of practice.
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