What Apgar score should a nurse document for a newborn with a pink trunk and head, bluish hands and feet, flexed extremities 5 min after delivery, a weak and slow cry, a heart rate of 130/min, and cries in response to suctioning?
7
8
9
10
The Correct Answer is B
Choice A rationale
An Apgar score of 7 is considered fairly low and would typically be associated with a newborn who has more significant health concerns.
Choice B rationale
An Apgar score of 8 is considered to be within the normal range. This score would be consistent with a newborn who has a pink trunk and head, bluish hands and feet, flexed extremities, a weak and slow cry, a heart rate of 130/min, and cries in response to suctioning.
Choice C rationale
An Apgar score of 9 is considered to be within the normal range. However, given the newborn’s weak and slow cry, an Apgar score of 9 would be less likely.
Choice D rationale
An Apgar score of 10 is very unusual, as almost all newborns lose 1 point for blue hands and feet, which is normal for after birth.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Excessive uterine enlargement is a common finding in a client with a hydatidiform mole. This is due to the overgrowth of trophoblastic tissue, which forms the placenta.
Choice B rationale
Profuse, clear vaginal discharge is not typically associated with a hydatidiform mole. The most common symptom is vaginal bleeding, which can be dark brown or bright red, and sometimes is described as looking like prune juice.
Choice C rationale
An irregular fetal heart rate is not a typical finding in a client with a hydatidiform mole, as this condition often results in a nonviable pregnancy.
Choice D rationale
A rapid decline in human chorionic gonadotropin (hCG) levels is not expected in a client with a hydatidiform mole. In fact, hCG levels are usually abnormally high in these cases.
Correct Answer is D
Explanation
Choice A rationale
Placing pillows under the patient’s knees when resting in bed can actually increase the risk of thromboembolic disease by slowing blood flow and promoting clot formation.
Choice B rationale
Massaging the patient’s posterior lower legs is not recommended, especially if the patient is showing signs of a possible deep vein thrombosis (DVT), as it could dislodge a clot.
Choice C rationale
Applying warm, moist heat to the patient’s lower extremities is not typically recommended as a primary intervention for patients with a history of thromboembolic disease.
Choice D rationale
Having the patient ambulate can help prevent the formation of blood clots by promoting blood circulation.
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