Nokea
The nurse is assessing Apgar score on a newborn. What will be evaluated?
- A. Reflexes
- B. Color
- C. Heart rate
- D. Respiration
- E. Weight
Correct Answer: A,B,C,D
Rationale: The Apgar score evaluates heart rate, respiration, muscle tone, reflexes, and color at 1 and 5 minutes after birth.
You may also like to solve these questions
What will the nurse expect the stool color to be 2 days after birth?
- A. Yellow
- B. Brown
- C. Greenish brown
- D. Black and tarry
Correct Answer: A
Rationale: The stool of a breastfed infant is bright yellow, soft, and pasty by 2 days after birth.
What action does the nurse implement to protect newborns from infection while in the nursery?
- A. Keep the newborn dressed warmly.
- B. Adjust room temperature between 23.8?°C (75?°F) and 26.6?°C (80?°F).
- C. Wash hands before touching each infant.
- D. Wear a disposable gown when giving infant care.
Correct Answer: C
Rationale: Hand washing is the most reliable precaution to prevent infection between handling different babies.
The nurse reminds new parents that newborns must be protected from environments that are too cold or too hot because of which aspects of their physiology?
- A. Very little subcutaneous fat
- B. Low metabolic rates
- C. Ineffective sweat glands
- D. Small fluid reserves
- E. Low red blood cell counts
Correct Answer: A,C
Rationale: Newborns have very little subcutaneous fat and ineffective sweat glands, making them susceptible to thermal stress.
The nurse is measuring the vital signs of a calm, full-term newborn. Which finding is abnormal?
- A. An axillary temperature of 36.6?°C (98?°F)
- B. An apical pulse rate of 178 beats/minute
- C. Respirations of 35 breaths/minute
- D. Blood pressure of 80/50 mm Hg
Correct Answer: B
Rationale: The normal range for a newborn's pulse rate is 110 to 160 beats/minute. A pulse rate of 178 beats/minute is abnormal and should be reported.
The nurse should consider which correct information when responding?
- A. Voice recognition is delayed because the ears are not well developed at birth.
- B. Infants respond to voice by increasing movements and sucking.
- C. Infants initially respond to low-pitched voices.
- D. Neonates can distinguish a mother's voice from other sounds in the first days of life.
Correct Answer: D
Rationale: The ability to discriminate between a mother's voice and other voices may occur as early as in the first 3 days of life.