The nursery nurse begins caring for the infant in the delivery room as soon as the infant is delivered.
When is the appropriate time for the nurse to perform the appearance, pulse, grimace, activity, and respiration (APGAR) assessment?
When the infant has signs of distress, such as difficulty breathing.
The health care provider will perform the first Apgar assessment.
At least twice, 1 minute and 5 minutes after birth.
Every 15 minutes during the first hour after birth.
The Correct Answer is C
Neonatal transition assessment requires specific timing to evaluate extrauterine adaptation accurately. Knowledge of the APGAR scoring system, which measures heart rate, respiratory effort, muscle tone, reflex irritability, and color, must be applied to determine the infant's immediate clinical status.
Choice A rationale
While signs of distress require immediate intervention, APGAR scoring is a standardized tool used for all newborns regardless of clinical appearance. Waiting for distress ignores the preventive and baseline value of the scheduled one-minute and five-minute assessments.
Choice B rationale
Although providers may be present, the nurse often performs the APGAR assessment in the delivery room. Nurses are trained to evaluate the five parameters to determine if neonatal resuscitation protocols, such as positive pressure ventilation, are necessary.
Choice C rationale
Standard practice dictates APGAR scoring at one and five minutes after birth. A score of 7 to 10 is normal. If the five-minute score is < 7, assessments continue every five minutes for up to twenty minutes.
Choice D rationale
Assessing APGAR every fifteen minutes is not standard practice and would interfere with thermoregulation and bonding. Vital signs are monitored frequently during the first hour, but the specific APGAR tool is limited to the immediate transition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Umbilical cord care focuses on preventing infection and promoting natural desiccation. Nurses apply principles of aseptic technique and health promotion to educate parents on identifying omphalitis and maintaining the cord site until the stump naturally separates from the neonate's abdomen.
Choice A rationale
Redness, edema, or foul smelling drainage are cardinal signs of omphalitis, a potentially serious infection. Parents must be taught to monitor the site closely and report these findings immediately to ensure prompt medical evaluation and antibiotic treatment.
Choice B rationale
The umbilical cord typically undergoes dry gangrene and falls off within 7 to 14 days after birth. Telling parents it takes a month is inaccurate and may cause unnecessary concern or delay the identification of delayed cord separation.
Choice C rationale
The diaper should be folded down below the umbilical stump. Keeping the cord outside the diaper prevents contamination from urine or feces and allows air exposure, which facilitates the drying process necessary for the cord to fall off.
Choice D rationale
The cord must be kept clean and dry to promote healing and separation. Moisture at the site encourages bacterial growth and delays the drying process. Current evidence based practice emphasizes dry cord care over the application of various liquids..
Correct Answer is B
Explanation
Evaluating maternal health in preeclampsia requires understanding HELLP syndrome, which involves hemolysis, elevated liver enzymes, and low platelets. Nurses must apply knowledge of hematologic shifts and normal lab ranges to identify life-threatening complications requiring immediate provider notification for patient safety.
Choice A rationale
Normal aspartate aminotransferase and alanine aminotransferase levels are typically 4 to 36 units/L. This value is within the upper normal range, indicating no significant hepatic cell destruction or inflammation characteristic of the HELLP syndrome triad.
Choice B rationale
Normal hematocrit for pregnant women exceeds 33 percent. A level of 21 percent indicates severe hemolysis or blood loss. In preeclampsia, this suggests microangiopathic hemolytic anemia, a critical component of HELLP syndrome requiring urgent intervention.
Choice C rationale
Normal hemoglobin during pregnancy is above 11 g/dL. While 8 g/dL is low, the hematocrit of 21 percent represents a more profound deviation from the three-to-one ratio, signifying more acute physiological instability regarding oxygen-carrying capacity.
Choice D rationale
Normal blood urea nitrogen levels range from 7 to 20 mg/dL. A value of 15 mg/dL is within normal limits, suggesting that renal filtration and perfusion remain adequate despite the systemic vasoconstriction common in worsening preeclampsia.
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