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
A newborn typically begins to void within 24 hours after birth, so not voiding within this time frame is not immediately concerning.
Choice B rationale
Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns, especially within the first few hours after birth. It is a normal finding and does not require immediate intervention.
Choice C rationale
A temperature of 37.5°C (99.5°F) is within the normal range for a newborn. Therefore, this does not require immediate attention.
Choice D rationale
Newborns typically pass meconium, the first stool, within 24 to 48 hours after birth. If a newborn has not passed meconium within 24 hours, it could indicate a problem such as meconium ileus, a complication of cystic fibrosis, or other conditions that might obstruct the bowel. This situation requires immediate attention and intervention.
Correct Answer is D
Explanation
Choice A rationale
While it is important to monitor a client’s temperature regularly, especially if they have a fever, simply checking the client’s temperature in 4 hours is not an adequate response to a temperature of 38.9°C (102°F) in a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. This could indicate an infection, which could be dangerous for both the mother and the baby.
Choice B rationale
Administering glucocorticoids intramuscularly is not typically the first-line treatment for a fever in a pregnant woman. Glucocorticoids are often used to accelerate fetal lung maturity in preterm labor, but they are not typically used to treat infections or fevers.
Choice C rationale
Preparing the client for an emergency cesarean section may be necessary if the client’s condition worsens or if there are other complications, but it is not the immediate response to a fever. The first step would be to identify and treat the cause of the fever, which could be an infection.
Choice D rationale
Administering acetaminophen orally is an appropriate nursing action for a client with a fever. Acetaminophen can help to reduce the client’s fever and make her more comfortable. However, it is also important to identify and treat the underlying cause of the fever, which could be an infection.
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