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A 6-lb, 8-oz neonate was delivered vaginally at 38 weeks' gestation. At 5 minutes of life, the neonate has the following signs: heart rate 110 , intermittent grunting with respiratory rate of 70 , flaccid tone, no response to stimulus, overall pale white in color. The Apgar score is:
- A. 2
- B. 3
- C. 4
- D. 6
Correct Answer: B
Rationale: Heart rate 110 (2 points), respiratory effort with grunting (1 point), flaccid tone (0 points), no response to stimulus (0 points), pale white color (0 points). Total Apgar score = 3.
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A primiparous client asks how to store breast milk safely at room temperature. The nurse should instruct the client that breast milk can be left at room temperature for up to:
- A. 2 hours.
- B. 4 hours.
- C. 6 hours.
- D. 8 hours.
Correct Answer: C
Rationale: Breast milk is safe at room temperature (up to 77°F) for up to 6 hours, minimizing bacterial growth.
The nurse is working with four clients on the obstetrical unit. Which client will be the highest priority for a cesarean section?
- A. Client at 40 weeks' gestation whose fetus weighs 8 lb by ultrasound estimate.
- B. Client at 37 weeks' gestation with fetus in ROP position.
- C. Client at 32 weeks' gestation with fetus in breech position.
- D. Client at 38 weeks' gestation with active herpes lesions.
Correct Answer: D
Rationale: Active herpes lesions necessitate a cesarean delivery to prevent neonatal transmission.
To determine whether a primigravid client in labor with a fetus in the left occipitoanterior (LOA) position is completely dilated, the nurse performs a vaginal examination. During the examination the nurse should palpate which of the following cranial sutures?
- A. Sagittal.
- B. Lambdoidal.
- C. Coronal.
- D. Frontal.
Correct Answer: A
Rationale: In the LOA position, the fetus's occiput is anterior, and the sagittal suture (running midline along the skull) is most accessible during vaginal examination to assess dilation and fetal position. Other sutures are less prominent in this presentation.
A male neonate born at 36 weeks' gestation is admitted to the neonatal intensive care nursery with a diagnosis of probable fetal alcohol syndrome (FAS). The mother visits the nursery soon after the neonate is admitted. Which of the following instructions should the nurse expect to include when developing the teaching plan for the mother about FAS?
- A. Withdrawal symptoms usually do not occur until 7 days postpartum.
- B. Large-for-gestational-age size is common with this condition.
- C. Facial deformities associated with FAS can be corrected by plastic surgery.
- D. Symptoms of withdrawal include tremors, sleeplessness, and seizures.
Correct Answer: D
Rationale: Symptoms of withdrawal in FAS include tremors, sleeplessness, and seizures due to neurological effects of alcohol exposure.
While caring for a primigravid client with class II heart disease at 28 weeks' gestation, the nurse would instruct the client to contact her physician immediately if the client experiences which of the following?
- A. Mild ankle edema.
- B. Emotional stress on the job.
- C. Weight gain of 1 lb in 1 week.
- D. Increased dyspnea at rest.
Correct Answer: D
Rationale: Increased dyspnea at rest can indicate worsening heart function.