Nokea
A 5-minute-old newborn in a delivery room has a good cry, HR 88, well flexed, good reflex irritability, and blue extremities with a completely pink body. What Apgar score would the nurse document for this newborn?
Correct Answer: 8
Rationale: The newborn would receive one point because the HR is below 100 bpm, two points for a good cry (respiratory effort), two points for being well flexed (muscle tone), two points for good reflex irritability (reflex response), and one point for a pink body with blue extremities (color).
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The client, who is 12 days postpartum, telephones the clinic and tells the nurse that she is concerned that she may have an infection because her vaginal discharge has been creamy white for two days now. Which response by the nurse is correct?
- A. “You need to come to the clinic as soon as possible.”
- B. “You’ll need an antibiotic; which pharmacy do you use?”
- C. “Take your temperature and let me know if it is elevated.”
- D. “A creamy white discharge 10 days postpartum is normal.”
Correct Answer: D
Rationale: There is no need to be seen in the clinic; vaginal discharge that turns creamy white 10 days postpartum is normal. The client does not have an infection, and no antibiotic is necessary. There is no reason to take her temperature when the discharge is normal. Creamy white discharge 10 to 21 days postpartum is normal. Her lochia changed color on her 10th postpartum day.
The nurse advises the client to keep the newborn's crib free of which item?
- A. Soft toys and blankets
- B. Firm mattress
- C. Fitted sheet
- D. Crib bumpers
Correct Answer: A
Rationale: Soft toys and blankets in the crib increase the risk of suffocation and SIDS, and should be avoided.
The client admitted in preterm labor is told that an amniocentesis needs to be performed. The client asks the nurse why this is necessary when the HCP has been performing ultrasounds throughout the pregnancy. Which is an appropriate response by the nurse?
- A. “Your baby is older now, and an amniocentesis provides us with more information on how your baby is doing.”
- B. “An amniocentesis could not be Performed before 32 weeks, so you will be having this test from now until delivery.”
- C. “Your doctor wants to make sure that there are no problems with the baby that an ultrasound might not be able to identify.”
- D. “With your preterm labor your doctor needs to know your baby’s lung maturity; this is best identified by amniocentesis.”
Correct Answer: D
Rationale: The amniocentesis is being performed to determine fetal lung maturity. Once fetal lung maturity is determined, appropriate care can be planned, including administration of betamethasone, administration of tocolytics, or delivery of the baby. While an amniocentesis can provide fetal information that an ultrasound cannot, the rationale for the amniocentesis is to determine lung maturity. Stating additional information is too broad. An amniocentesis can be performed as early as 12 weeks’ gestation, not after 32 weeks. The amniocentesis is not being performed to identify fetal anomalies.
Which newborn behavior is normal and does not require immediate concern?
- A. Frequent hiccups
- B. Persistent vomiting
- C. Lethargy for days
- D. High fever
Correct Answer: A
Rationale: Frequent hiccups are normal in newborns and typically resolve without intervention, unlike the other symptoms.
When teaching the class about varicose veins, which symptom should the nurse instruct clients to report immediately?
- A. The appearance of additional varicose veins
- B. Varicose veins that are purple in color
- C. Legs that begin to ache and feel heavy
- D. Calves that become red, tender, and warm
Correct Answer: D
Rationale: Red, tender, warm calves may indicate deep vein thrombosis, a serious condition requiring immediate reporting.