The nurse is caring for an infant delivered one minute ago. The infant has no spontaneous respirations, no response to stimulus, is limp, pale, and has a heart rate of 99 beats per minute.

How will the nurse document this infant's APGAR Score?

Enter number only (no units).

Answer and Explanation

The Correct Answer is ["1"]

The APGAR score assesses five criteria: Appearance (skin colour), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration (breathing effort). Each criterion is scored from 0 to 2, with a maximum total score of 10.

Appearance: The infant is pale, which scores 0.
Pulse: The heart rate is 99 beats per minute, which scores 1 (as it is below 100).
Grimace: No response to stimulus, which scores 0.
Activity: The infant is limp, which scores 0.
Respiration: No spontaneous respirations, which scores 0.

Summing these scores gives a total APGAR score of 1.

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Correct Answer is C

Explanation

Choice A reason: Waiting until the urge to push before going to the hospital is not advisable. If the water has broken, it indicates that Labor may be starting, and the pregnant person should be evaluated to ensure the safety of both the parent and the baby.

Choice B reason: Waiting for contractions to start before calling back is not recommended. If the water has broken, there is a risk of infection and other complications, so immediate evaluation is necessary.

Choice C reason: Coming to the Labor and delivery unit for an evaluation is the correct response. When the water breaks, it is important to assess the mother and baby to determine the next steps and ensure that both are healthy and safe.

Choice D reason: Drinking water and lying down is not an appropriate response to the water breaking. While staying hydrated is important during pregnancy, the priority should be to seek immediate medical evaluation.

A. Prepare to hang hypotonic fluids. B. Administer oxygen via nasal cannula. C. Provide patient education on acute chest syndrome. D. Give a dose of morphine sulphate.

Correct Answer is B

Explanation

Choice A reason: Preparing to hang hypotonic fluids is not the immediate priority in this situation. While hydration is important for managing sickle cell anaemia, the infant's respiratory distress and low oxygen saturation levels indicate that addressing oxygenation should be the first step. Hypotonic fluids may be considered after stabilizing the patient's breathing and oxygen levels.

Choice B reason: Administering oxygen via nasal cannula is the priority intervention given the infant's symptoms. The infant has increased work of breathing, a fever, coarse crackles upon auscultation, and low oxygen saturation (89%). Providing supplemental oxygen is crucial to improve oxygenation and alleviate respiratory distress. Prompt intervention is necessary to prevent further complications and stabilize the patient's condition.

Choice C reason: Providing patient education on acute chest syndrome is important, but it is not the immediate priority in this emergency situation. Education can be given once the infant's acute symptoms are managed and stabilized. The focus should be on addressing the critical needs first, such as oxygenation and respiratory support.

Choice D reason: Giving a dose of morphine sulphate may help manage pain, but it is not the first priority in this scenario. The infant's respiratory status and oxygenation levels are more critical and require immediate attention. Pain management can be addressed after ensuring the infant's breathing and oxygen levels are stabilized.

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The nurse is caring for an infant delivered one minute ago. The infant has no spontaneous respirations, no response to stimulus, is limp, pale, and has a heart rate of 99 beats per minute. How will the nurse document this infant's APGAR Score? Enter number only (no units).

Nursing Test Bank

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The nurse is caring for an infant delivered one minute ago. The infant has no spontaneous respirations, no response to stimulus, is limp, pale, and has a heart rate of 99 beats per minute.

How will the nurse document this infant's APGAR Score?

Enter number only (no units).