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Newborn boy, 1 minute after birth, heart rate 138 bpm, vigorous crying, spontaneous movement, pink skin with bluish hands and feet
Erin gives birth to a boy. The nurse notes the following on the baby at 1 minute: heart rate is 138 bpm, loud vigorous crying, spontaneous movement and flexion of the extremities, and pink skin color except for a bluish color of the hands and feet. What Apgar score will be assigned to the baby?
- A. 7
- B. 8
- C. 9
- D. 10
Correct Answer: B
Rationale: The baby scores 2 for heart rate (>100 bpm), 2 for respiratory effort (vigorous crying), 2 for muscle tone (spontaneous movement), 2 for reflex irritability (crying), and 1 for color (acrocyanosis), totaling an Apgar score of 8.
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Primigravida client in second stage of labor, moaning and screaming, husband requests pain medication
A primigravida client in the second stage of labor has been moaning, screaming, and generally vocal throughout her labor. Her husband is distraught seeing his wife this way and asks the nurse for more pain medication for her. What is the nurse's best response?
- A. Assist the client with breathing and imagery techniques in an attempt to calm her down.
- B. Ask the client to describe the intensity of her pain on a scale of 0 to 10.
- C. Page the obstetrician to evaluate the client's pain, and administer an appropriate increase in her pain medication.
- D. Reassure the first-time father that his wife will be fine, and offer to stay with her while he takes a walk.
Correct Answer: A
Rationale: Assisting with breathing and imagery techniques provides nonpharmacological pain relief and supports the client's coping mechanisms, which is appropriate as vocalizing is a normal way to express pain during labor.
Newborn placed under radiant heat warmer after birth
A nurse places a newborn under a radiant heat warmer after birth. The purpose of this action is to prevent which of the following in the newborn?
- A. Basal metabolic rate reduction.
- B. Brown fat production.
- C. Shivering.
- D. Cold stress.
Correct Answer: D
Rationale: A radiant heat warmer prevents cold stress by maintaining the newborn's body temperature, avoiding complications like hypoxia and hypoglycemia.
Woman gave birth vaginally to a 9-pound, 12-ounce girl yesterday, orders for perineal ice packs, sitz bath, stool softener
A woman gave birth vaginally to a 9-pound, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of a sitz bath tid, and a stool softener. What information is most closely correlated with these orders?
- A. The woman had a vacuum-assisted birth.
- B. The woman is a gravida 2, para 2.
- C. The woman has an episiotomy.
- D. The woman received epidural anesthesia.
Correct Answer: C
Rationale: An episiotomy correlates with orders for ice packs, sitz baths, and stool softeners, as these address pain and healing of the perineal incision.
Primigravida client at term, having contractions, unsure if in labor
A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is 'not really sure if she is in labor or not.' Which of the following should the nurse recognize as a sign of true labor?
- A. Rupture of the membranes.
- B. Pattern of contractions.
- C. Changes in the cervix.
- D. Station of the presenting part.
Correct Answer: C
Rationale: Changes in the cervix, such as effacement and dilation, are the most accurate indicators of true labor, caused by contractions and fetal pressure.
Newborn, preventing heat loss
To prevent heat loss from convection in a newborn, which action by the nurse is best?
- A. Dry the baby after a bath.
- B. Wrap the baby in warmed blankets.
- C. Place the baby in a warmer.
- D. Move infant away from blowing fan.
Correct Answer: D
Rationale: Moving the infant away from a blowing fan directly prevents heat loss due to air movement, which is a key factor in convection.