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A nurse observes 5 minutes after delivery that a newborn has a pink trunk and head, bluish hands and feet, and a heart rate of 130/min. He has flexed extremities and a weak, slow cry. The nurse should document what Apgar score for this infant?
- A. 5
- B. 6
- C. 7
- D. 8
- E. 9
Correct Answer: B
Rationale: The correct Apgar score for this infant is B: 6. The Apgar score assesses a newborn's overall condition at 1 and 5 minutes after birth based on five criteria: Appearance, Pulse, Grimace, Activity, and Respiration. In this case, the baby has a pink trunk and head (2 points), bluish hands and feet (1 point), a heart rate of 130/min (2 points), flexed extremities (2 points), and a weak, slow cry (1 point). Adding these points together, the Apgar score is 2+1+2+2+1=8. Since the Apgar score ranges from 0 to 10, a score of 6 indicates that the infant may need some assistance but is generally in good condition. Other choices are incorrect because they do not add up correctly based on the described criteria.
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A nurse is caring for a newborn and assessing newborn reflexes. To elicit the Moro reflex, the nurse should take which of the following actions?
- A. Place a finger at the base of the newborn’s toes.
- B. Turn the newborn’s head quickly to one side.
- C. Hold the newborn vertically allowing one foot to touch the table surface.
- D. Perform a sharp hand clap near the infant.
Correct Answer: D
Rationale: The Moro reflex is a startle reflex observed in newborns. To elicit this reflex, a sudden loud noise or movement is needed. Performing a sharp hand clap near the infant is the appropriate action to trigger the Moro reflex. This action mimics a sudden loud noise, causing the baby to extend the arms and legs, then bring them back in a hugging motion. Placing a finger at the base of the newborn's toes (Choice A) does not elicit the Moro reflex. Turning the newborn's head quickly to one side (Choice B) triggers the asymmetric tonic neck reflex, not the Moro reflex. Holding the newborn vertically allowing one foot to touch the table surface (Choice C) elicits the stepping reflex, not the Moro reflex.
A nurse is preparing to assess a newborn who is post-term. Which of the following findings should the nurse expect? (Select all that apply)
- A. Vernix in the folds and creases
- B. Abundant lanugo
- C. Positive Moro reflex
- D. Cracked peeling skin
- E. Short soft fingernails
Correct Answer: A,C,D
Rationale: The correct answers are A, C, and D. A post-term newborn is born after 42 weeks of gestation, which can lead to certain physical characteristics.
A: Vernix in the folds and creases is expected in post-term newborns due to prolonged exposure to amniotic fluid.
C: Positive Moro reflex is expected as it indicates the baby's neurological maturity.
D: Cracked peeling skin is common in post-term newborns due to prolonged exposure to amniotic fluid, leading to dryness.
B: Abundant lanugo is typically seen in premature newborns rather than post-term.
E: Short soft fingernails are not specific to post-term newborns.
A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia?
- A. 3+ protein in the urine.
- B. Deep tendon reflexes of 1+.
- C. Blood pressure 148/98 mm Hg.
- D. 1+ pitting sacral edema.
Correct Answer: B
Rationale: The correct answer is B. Deep tendon reflexes of 1+ are inconsistent with preeclampsia. In preeclampsia, deep tendon reflexes are typically hyperactive (3+ or 4+). This is due to the central nervous system irritability caused by hypertension. Therefore, a reflex of 1+ suggests normal reflexes, which is not expected in preeclampsia. Other choices A, C, and D are consistent with preeclampsia. Proteinuria (choice A) is a hallmark sign of preeclampsia. Elevated blood pressure (choice C) is a common finding in preeclampsia. Pitting edema (choice D) is also commonly observed in preeclampsia due to fluid retention.
A nurse in a prenatal clinic is caring for a client who is suspected of having a hydatidiform mole. Which of the following findings should the nurse expect to observe in this client?
- A. Rapid decline in human chorionic gonadotropin (hCG) levels
- B. Irregular fetal heart rate
- C. Excessive uterine enlargement
- D. Profuse, clear vaginal discharge
Correct Answer: C
Rationale: The correct answer is C: Excessive uterine enlargement. A hydatidiform mole is a gestational trophoblastic disease characterized by abnormal growth of placental tissue in the uterus, leading to excessive uterine enlargement. This condition results in the absence of a viable fetus and can cause symptoms such as vaginal bleeding, severe nausea, and hypertension. The other choices are incorrect because: A) Rapid decline in hCG levels is not a typical finding in a hydatidiform mole, as hCG levels are usually elevated. B) Irregular fetal heart rate is not applicable in this case since there is no viable fetus. D) Profuse, clear vaginal discharge is not a characteristic symptom of a hydatidiform mole. E, F, and G are not provided as options.
A nurse is caring for a client who is postpartum. The client tells the nurse that the newborn’s maternal grandmother was born deaf and asks how to tell if her newborn hears well. Which of the following statements should the nurse make?
- A. “There is no need to worry about that. Most forms of hearing loss are not inherited.”
- B. “We do routine hearing screenings on newborns. You’ll know the results before you leave the hospital.”
- C. “The best way to determine if your baby can hear is to clap your hands loudly and see if she startles.”
- D. “Look at how she looks at you when you speak. That’s a good sign.”
Correct Answer: B
Rationale: Rationale: Choice B is correct because routine hearing screenings for newborns are a standard practice to assess hearing ability. This screening is important for early detection and intervention if hearing loss is present. The other choices are incorrect because: A dismisses the client's concerns and provides inaccurate information, C is not a reliable method to assess hearing, and D, while somewhat accurate, does not provide a definitive assessment like a hearing screening would.