Nokea
The nurse is doing a one-minute Apgar score on a newborn and tells the parents that it is 7 points. When the parents ask what this means, how should the nurse best respond?
- A. “This score is good, but the baby needs to have a score of 10 in five minutes.”
- B. “The Apgar score can predict intelligence and neurological development.”
- C. “Your baby is fine and should have no difficulty adapting outside the womb.”
- D. “Your baby has good vital signs and is classified as full-term gestational age.”
Correct Answer: C
Rationale: This response is best because a score of 7 to 10 is within a normal range and 并表示新生儿没有任何不适的迹象。A score of 7 to 10 is considered acceptable for a one-minute Apgar. However, when the scoring is repeated at 5 minutes of age, a score of 7 to 10, not just 10, is within normal range. The Apgar score is used to systematically assess an infant at one and five minutes after birth to determine if immediate care is necessary. It is not used to predict intelligence or neurological development. Although the Apgar score does mean that the newborn’s VS are WNL, the Apgar score is not designed to classify gestational age.
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The nurse correctly instructs the client to contact the physician immediately under which circumstance?
- A. When the first fetal movement is felt
- B. If the breasts become tender
- C. If vaginal bleeding occurs
- D. When experiencing frequent urination
Correct Answer: C
Rationale: Vaginal bleeding is a danger sign in pregnancy, potentially indicating miscarriage or placental issues, requiring immediate reporting.
Which nursing instruction is most appropriate regarding the relief of itchy skin during pregnancy?
- A. Take a hot bath daily.
- B. Increase fluid intake.
- C. Add a daily vitamin C tablet to the diet.
- D. Take diphenhydramine (Benadryl) twice per day.
Correct Answer: B
Rationale: Increasing fluid intake hydrates the skin, reducing itchiness, while hot baths or antihistamines may worsen symptoms or require medical approval.
The nurse includes which activity to promote bonding with the fetus?
- A. Talking or singing to the fetus
- B. Watching television daily
- C. Avoiding fetal movement monitoring
- D. Limiting prenatal visits
Correct Answer: A
Rationale: Talking or singing to the fetus promotes early bonding and stimulates fetal development.
The nurse is caring for the client who just gave birth. Which observation of the client should lead the nurse to be concerned about the client’s attachment to her male infant?
- A. Asking the caregiver about how to change his diaper
- B. Comparing her newborn’s nose to her brother’s nose
- C. Calling the baby “Kelly,” which was the name selected
- D. Repeatedly telling her husband that she wanted a girl
Correct Answer: D
Rationale: Seeking information about infant care is a sign that the mother is developing attachment to her infant. Pointing out family traits or characteristics seen in the newborn is a sign that the mother is developing attachment. Calling the infant by name is a sign that the mother is developing attachment to her infant. Attachment is demonstrated by expressing satisfaction with a baby’s appearance and sex. Frequent expressions of dissatisfaction with the sex of the infant should be concerning and followed up.
The nurse reviews information and assesses the laboring client at 42 weeks’ gestation before an HCP induces labor. Which findings should be reported to the HCP because they are contraindications to labor induction? Select all that apply.
- A. Umbilical cord prolapse
- B. Transverse fetal lie
- C. Cervical dilation not progressing
- D. Premature rupture of membranes
- E. Previous cesarean incision
Correct Answer: A,B,E
Rationale: Inducing labor with an umbilical cord prolapsed can cause fetal trauma and is contraindicated. This should be reported to the HCP. Inducing labor with a transverse fetal lie can produce trauma to the fetus and mother and is contraindicated. This should be reported to the HCP. Women with a previous cesarean incision should not be stimulated because it is a contraindication for a vaginal birth and warrants an immediate repeat cesarean birth. This should be reported to the HCP. Lack of progressive cervical dilation is an indication for labor induction, not a contraindication. Premature rupture of the membranes is an indication for labor induction, not a contraindication.