Nokea
The nurse is calculating the Apgar score for a newborn. Findings are as follows: Heart rate: 110, Respiratory effort: good cry, Muscle tone: some flexion of extremities, Reflex irritability: grimace, Color: completely pink. What is the Apgar score for this neonate?
- A. 7
- B. 8
- C. 9
- D. 10
Correct Answer: C
Rationale: Heart rate 110 (2), good cry (2), some flexion (1), grimace (1), pink (2) = 9.
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The nurse is preparing to teach a client about the prescribed furosemide (Lasix). The nurse should instruct the client about which adverse effect?
- A. increased appetite
- B. leg cramps
- C. anorexia
- D. dry mouth
Correct Answer: B
Rationale: Furosemide can cause electrolyte imbalances, such as hypokalemia, leading to leg cramps. Other effects are less common.
The surgical nurse is preparing a patient for surgery on the lower abdomen. In which position would the nurse most likely place the client for surgery on this area?
- A. Lithotomy
- B. Sim's
- C. Prone
- D. Trendelenburg
Correct Answer: D
Rationale: Trendelenburg position (head down, feet elevated) is used for lower abdominal surgery to improve access to the pelvic organs by shifting abdominal contents upward.
When planning the care for a client after a posterior fossa (infratentorial) craniotomy, which action is contraindicated?
- A. Keeping the client flat on one side
- B. Elevating the head of the bed 30°
- C. Log-rolling or turning as a unit
- D. Keeping the neck in a neutral position
Correct Answer: B
Rationale: Elevating the head of the bed can increase intracranial pressure in posterior fossa craniotomy clients due to disruption of cerebrospinal fluid flow, making it contraindicated.
Which one of the following infants needs a further assessment of growth?
- A. 4-month-old: birth weight 7 lb, 6 oz; current weight 14 lb, 4 oz
- B. 2-week-old: birth weight 6 lb, 10 oz; current weight 6 lb, 12 oz
- C. 6-month-old: birth weight 8 lb, 8 oz; current weight 15 lb
- D. 2-month-old: birth weight 7 lb, 2 oz; current weight 9 lb, 6 oz
Correct Answer: B
Rationale: The 2-week-old has only gained 2 oz since birth, which is inadequate (normal is 0.5-1 oz/day), indicating a need for growth assessment.
After several hospitalizations for respiratory ailments, a 6-month-old has been diagnosed as having HIV. The infant's respiratory ailments were most likely due to:
- A. Pneumocystis carinii
- B. Cytomegalovirus
- C. Cryptosporidiosis
- D. Herpes simplex
Correct Answer: A
Rationale: Pneumocystis carinii (now Pneumocystis jirovecii) is a common cause of pneumonia in HIV-infected infants.