The nurse is calculating the one-minute Apgar score for a newborn infant and determines that the heart rate is 150 beats/minute, a vigorous cry is present, muscle tone is good with total flexion, quick reflex irritability noted, and skin color is dusky and cyanotic.

Which Apgar score should the nurse assign to this infant?

(Enter numeric value only.)

Answer and Explanation

The Correct Answer is ["9"]

To determine the Apgar score for the newborn infant, we assess five parameters: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Each parameter is scored from 0 to 2, with 2 being the highest score. Let's evaluate each parameter:

Heart rate: 150 beats/minute --> Score of 2.
Respiratory effort: Vigorous cry present --> Score of 2.
Muscle tone: Good muscle tone with total flexion --> Score of 2.
Reflex irritability: Quick reflex irritability noted --> Score of 2.
Color: Dusky and cyanotic skin color --> Score of 1.

Now, we sum up the scores: 2+2+2+2+1=92+2+2+2+1=9

Therefore, the Apgar score for this infant is 9.

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Correct Answer is C

Explanation

A. Use a stethoscope to listen to and compare breath sounds anteriorly and posteriorly. This action is used to assess breath sounds, not tactile fremitus.

B. Looking at the client from the side, observe the size and shape of the chest wall. This action helps in assessing the general appearance and shape of the chest but does not assess tactile fremitus.

C. Place the palm of the hand on the chest wall to feel vibrations while the client speaks. This is the correct technique to assess tactile fremitus. Increased fremitus can indicate consolidation, as in pneumonia.

D. Use the fingertips to compress tissue over the lungs for evidence of a crackling sensation. This action is associated with palpating for crepitus, not assessing tactile fremitus.

A. Demonstrates startle reflex. B. Has doubled birth weight. C. Turns head to locate sound. D. Plays "peek a boo."

Correct Answer is A

Explanation

A. Demonstrates startle reflex: The startle reflex (Moro reflex) typically disappears around 3-4 months of age. If a 6-month-old still demonstrates this reflex, it may indicate a developmental delay or neurological issue, requiring further evaluation.

B. Has doubled birth weight: Doubling of birth weight by 6 months is a normal developmental milestone. This response does not require further evaluation as it indicates appropriate growth.

C. Turns head to locate sound: Turning the head to locate sounds is expected at this age and demonstrates normal auditory and neurological development. This response does not require further evaluation.

D. Plays "peek a boo": Playing "peek a boo" is a typical social interaction for a 6-month-old and indicates normal social and cognitive development. This response does not require further evaluation.

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Naxlex Comprehensive Predictor Exams

In assessing tactile fremitus in the client with suspected pneumonia, the nurse should perform which action?

Correct Answer is C

Explanation

The nurse is assessing a 6-month-old infant. Which response requires further evaluation by the nurse?

Correct Answer is A

Explanation

A pregnant, homeless woman who has received no prenatal care presents to the clinic in her third trimester because she is having vaginal bleeding, but reports that she is not in pain. Ultrasound reveals a placenta previa. Which action should the nurse implement?

While counting the respirations of an adult client who is bedfast, the nurse observes that the client uses the sternocleidomastoid, trapezius, and abdominal muscles during respirations. Which action should the nurse take in response to this finding?

During a routine health screening of an adult client, the nurse notes several changes that have occurred over the past year. Which change indicates the need for a bone density screening?

While assessing a client who is obese, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. Which is the most likely explanation for failure to locate the gallbladder by palpation?

While assessing a client, the nurse notices that the client's legs are asymmetrical. Which additional physical data should the nurse collect?

The nurse observes that a client is experiencing melena. Which serum laboratory test should the nurse monitor in response to this finding?

A client grimaces while preforming range of motion of the left knee during an annual health assessment. Which movements should the nurse utilize to assess the client's ability to normally perform range of motion on the right knee?

The nurse plans to conduct a physical assessment of a toddler. Which protocol is best for the nurse to implement?