You're assessing the one-minute APGAR score of a newborn baby. On assessment, you note the following about your newborn patient: weak cry, some flexion of the arm and legs, active movement and cries to stimulation, heart rate 145, and pallor all over the body and extremities. What is your patient's APGAR score?
APGAR 4
APGAR 6
APGAR 10
APGAR 9
The Correct Answer is B
A. A score of 4 would indicate severe distress, but the baby in this scenario shows signs of responsiveness and activity.
B. A score of 6 suggests moderate adaptation to extrauterine life, considering some components of the APGAR are within the normal range.
C. A score of 10 is perfect, but the noted symptoms suggest some difficulties.
D. A score of 9 would be high and not consistent with the observed signs of distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The presence of lochia rubra with small clots in the immediate postpartum period is expected. The firm and midline fundus indicates appropriate uterine contraction. Continued monitoring is appropriate.
B. Encouraging the client to empty her bladder is a valid intervention, but it is not the priority in this situation.
C. Increasing the frequency of fundal massage is unnecessary, as the fundus is already firm.
D. Notifying the provider is not necessary based on the described findings, as they are within the expected range.
Correct Answer is B
Explanation
A. Confirming that the newborn is at least 24 hours old is not a requirement for administering the HBV vaccine. The vaccine can be given to newborns shortly after birth, typically within 12 hours.
B. Obtaining a syringe with a 25-gauge, 5/8-inch needle for medication administration is correct. This needle size is appropriate for administering vaccines intramuscularly to newborns.
C. Assessing the dorsogluteal muscle as the preferred site for injection is incorrect; the ventrogluteal or vastus lateralis muscles are recommended for intramuscular injections in infants. The dorsogluteal site is not preferred for young children due to the risk of sciatic nerve injury.
D. Confirming that the newborn's mother has been infected with the HBV is not necessary for administering the vaccine, although if the mother is infected, the newborn should receive the HBV vaccine and hepatitis B immunoglobulin (HBIG) within 12 hours of birth.
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