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 A
Explanation
Choice A rationale
The client’s symptoms and lab results are consistent with HELLP Syndrome, a severe form of preeclampsia. HELLP stands for Hemolysis, Elevated Liver enzymes, and Low Platelet count. The client’s elevated liver enzymes and low platelets, along with the reported symptoms, are indicative of this condition.
Choice B rationale
While the client’s high blood pressure could suggest Postpartum hypertension, the presence of severe headaches, visual disturbances, right upper quadrant pain, and abnormal lab results point more towards HELLP Syndrome.
Choice C rationale
Hypertension in pregnancy could be a possibility, but it does not explain all of the client’s symptoms and lab results, particularly the elevated liver enzymes and low platelets.
Choice D rationale
Superimposed preeclampsia is a condition where a pregnant woman with chronic hypertension develops preeclampsia. However, the client’s severe symptoms and lab results are more indicative of HELLP Syndrome.
Correct Answer is A
Explanation
Choice A rationale
The priority action by the nurse following an amniotomy is to assess the fetal heart rate. This is because changes in the fetal heart rate can indicate fetal distress, which could be caused by cord compression or other complications related to the amniotomy.
Choice B rationale
While assessing the odor of the amniotic fluid is important to identify possible infections, it is not the priority action following an amniotomy.
Choice C rationale
Providing clean, dry underpads is part of standard care following an amniotomy, but it is not the priority action.
Choice D rationale
Monitoring the client’s temperature is important to identify possible infection, but it is not the priority action immediately following an amniotomy.
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