Nokea
The nurse notes that a newborn, who is 5 minutes old, exhibits the following characteristics: heart rate 108 bpm, respiratory rate 29 rpm with lusty cry, pink body with bluish hands and feet, some flexion. What does the nurse determine the baby's Apgar score is?
- A. 6
- B. 7
- C. 8
- D. 9
Correct Answer: C
Rationale: Scoring: Heart rate (2), respirations (2), color (1), muscle tone (2), reflex irritability (1). Total = 8.
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A postpartum client has been diagnosed with deep vein thrombosis. For which of the following additional complications is this client high risk?
- A. Hemorrhage.
- B. Stroke.
- C. Endometritis.
- D. Hematoma.
Correct Answer: B
Rationale: DVT increases stroke risk due to clot migration.
A client is receiving a blood transfusion after the delivery of a placenta accreta and hysterectomy. Which of the following complaints by the client would warrant immediately discontinuing the infusion?
- A. My lower back hurts all of a sudden.
- B. My hands feel so cold.
- C. I feel like my heart is beating fast.
- D. I feel like I need to have a bowel movement.
Correct Answer: A
Rationale: Back pain can indicate a hemolytic reaction.
The mother notes that her baby has a 'bulge' on the back of one side of the head. She calls the nurse into the room to ask what the bulge is. The nurse notes that the bulge covers the right parietal bone but does not cross the suture lines. The nurse explains to the mother that the bulge results from which of the following?
- A. Molding of the baby's skull so that the baby could fit through her pelvis.
- B. Swelling of the tissues of the baby's head from the pressure of her pushing.
- C. The position that the baby took in her pelvis during the last trimester of her pregnancy.
- D. Small blood vessels that broke under the baby's scalp during birth.
Correct Answer: A
Rationale: Molding occurs due to passage through the birth canal.
A 4-day-old breastfeeding neonate whose birth weight was 2,678 grams has lost 100 grams since the cesarean birth. Which of the following actions should the nurse take?
- A. Nothing because this is an acceptable weight loss.
- B. Advise the mother to supplement feedings with formula.
- C. Notify the neonatologist of the excessive weight loss.
- D. Give the baby dextrose water between breast feedings.
Correct Answer: A
Rationale: Weight loss within 5% is normal.
A woman who wishes to breastfeed advises the nurse that she has had breast augmentation surgery. Which of the following responses by the nurse is appropriate?
- A. Breast implants often contaminate the milk with toxins.
- B. The glandular tissue of women who need implants is often deficient.
- C. Babies often have difficulty latching to the nipples of women with breast implants.
- D. Women who have implants are often able exclusively to breastfeed.
Correct Answer: D
Rationale: Implants do not preclude breastfeeding.