When calculating a 1-minute APGAR, the nurse evaluates the following assessment data: Heart rate 120 BPM; strong cry; well-flexed; reflex-crying: body pink; acrocyanosis present in hands and feet.

In view of these findings, the nurse should assign an APGAR score of:

Choice A rationale

Brain death is a clinical diagnosis characterized by irreversible cessation of all functions of the entire brain, including the brainstem. If the client's heart is still beating and they can breathe on their own, it indicates preserved brainstem function, which is inconsistent with brain death criteria.

Choice B rationale

Brain death is defined as irreversible cessation of all brain functions. When a client is on life support, but their brain has sustained irreversible damage with complete loss of brainstem reflexes, they meet the criteria for brain death, allowing for organ donation consideration.

Choice C rationale

A client able to respond to stimuli and communicate with others exhibits clear signs of brain activity and consciousness. This directly contradicts the definition of brain death, which requires complete and irreversible loss of all brain function, including higher cortical functions.

Choice D rationale

While vital organs may eventually cease functioning after brain death, the initial and primary criterion for brain death is the irreversible cessation of brain function. The vital organs can often be maintained on life support for a period to facilitate organ donation, so they are not necessarily non-functioning.

Step 1 is to convert the child's weight from pounds to kilograms:. 13.2 lbs ÷ 2.2 lbs/kg = 6 kg.

Step 2 is to calculate the ordered dose in mg:. 25 mcg = 0.025 mg.

Step 3 is to calculate the volume to be drawn up for a single dose:. 0.025 mg ÷ (0.1 mg/mL) = 0.25 mL.