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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: Scheduling a full neurological evaluation is the appropriate action in this scenario. The sudden regression in the child's ability to walk is a significant concern that requires immediate investigation to rule out any underlying neurological or medical conditions. A full neurological evaluation will help identify any issues such as developmental delays, neuromuscular disorders, or other conditions that may be affecting the child's motor skills. Prompt evaluation and diagnosis are crucial for early intervention and appropriate management.

Choice B reason: Recommending follow-up in 30 days after documenting the regression is not an ideal approach in this situation. Given the severity of the regression in the child's walking ability, waiting for 30 days without further investigation could delay critical diagnosis and treatment. Immediate assessment is necessary to address potential underlying issues and provide timely intervention.

Choice C reason: Questioning the parents about changes in the child's activity schedule is important but should not be the sole action taken. While gathering information about the child's activities and environment can provide valuable context, it does not replace the need for a thorough medical evaluation. The primary concern here is the sudden regression in motor skills, which warrants a full neurological assessment.

Choice D reason: Documenting the findings and scheduling an 18-month well-visit is also not sufficient. While it is essential to document the observed regression, delaying further action until the next routine check-up could result in missed opportunities for early diagnosis and intervention. The priority should be to conduct a neurological evaluation to understand the cause of the regression and take appropriate steps to address it.

A. Diphtheria, Tetanus, and Pertussis (DTaP) B. Hepatitis B C. Inactivated Polio Vaccine (IPV) D. Pneumococcal 13 Vaccine (PCV13) E. Haemophilus Influenzae type B (Hib)

Correct Answer is ["A","B","C","D","E"]

Explanation

Choice A reason: The Diphtheria, Tetanus, and Pertussis (DTaP) vaccine is recommended for infants at 2, 4, and 6 months of age. It helps protect against three serious bacterial infections: diphtheria, tetanus, and pertussis.

Choice B reason: The Hepatitis B vaccine is usually administered at birth, 1-2 months, and 6-18 months. The 4-month visit may include this vaccine if it is part of the catch-up schedule or combined with other vaccines.

Choice C reason: The Inactivated Polio Vaccine (IPV) is given at 2, 4, and 6-18 months of age to protect against poliovirus, which can cause paralysis and other severe health issues.

Choice D reason: The Pneumococcal 13 Vaccine (PCV13) protects against 13 types of pneumococcal bacteria, which can cause serious infections like pneumonia, meningitis, and sepsis. It is typically given at 2, 4, and 6 months of age.

Choice E reason: The Haemophilus Influenzae type B (Hib) vaccine is administered at 2, 4, and 6 months of age to protect against infections caused by Hib bacteria, such as meningitis, pneumonia, and epiglottitis.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Naxlex Comprehensive Predictor Exams

The nurse is examining a 15-month-old child who was able to walk at the last visit and now can no longer walk. What will the nurse do?

Correct Answer is A

Explanation

A nurse is caring for a 4-month-old child during a well visit. Which vaccines will the nurse prepare to administer for this child? Select all that apply.

Correct Answer is ["A","B","C","D","E"]

Explanation

A nurse is reviewing data for patients on an inpatient unit. Which patient will the nurse see first?

The nurse receives shift report on four patients. Which patient will the nurse prioritize?

The nurse is preparing to discharge a mother/baby couplet from the maternity unit. Which action by the parents requires further teaching?

A pregnant person telephones the prenatal clinic and reports that their "water just broke." How will the nurse respond?

The nurse is administering digoxin as ordered and the child vomits the dose. What action will the nurse implement?

A nurse is caring for a full-term newborn diagnosed with persistent/patent ductus arteriosus (PDA). The newborn's caregiver asks the nurse, "What causes a PDA?" How will the nurse answer this question?

The emergency department nurse is assessing a 14-month-old child who was left inside a closed car for an hour. The outside temperature was 88 degrees Fahrenheit. Which assessment findings will the nurse report immediately to the health care provider? Select all that apply.

The nurse is assisting a patient 2 hours post-vaginal birth out of bed to the bathroom for the first time. Which interventions will the nurse implement? Select all that apply.

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).