Nokea
The predominant purpose of the first Apgar scoring of a newborn is to:
- A. Determine gross abnormal motor function
- B. Obtain a baseline for comparison with the infant's future adaptation to the environment
- C. Evaluate the infant's vital functions
- D. Determine the extent of congenital malformations
Correct Answer: C
Rationale: Apgar scores are not related to the infant's care, but to the infant's physical condition. Apgar scores assess the current physical condition of the infant and are not related to future environmental adaptation. The purpose of the Apgar system is to evaluate the physical condition of the newborn at birth and to determine if there is an immediate need for resuscitation. Congenital malformations are not one of the areas assessed with Apgar scores.
You may also like to solve these questions
A five-year-old is admitted to the unit following a tonsillectomy. Which of the following would indicate a complication of the surgery?
- A. Decreased appetite
- B. A low-grade fever
- C. Chest congestion
- D. Constant swallowing
Correct Answer: D
Rationale: Constant swallowing post-tonsillectomy suggests bleeding, as the child may be swallowing blood from the surgical site, a serious complication requiring immediate attention. Decreased appetite and low-grade fever are expected, and chest congestion is unrelated.
The nurse is caring for a client post-myocardial infarction on the cardiac unit. The client is exhibiting symptoms of shock. Which clinical manifestation is the best indicator that the shock is cardiogenic rather than anaphylactic?
- A. BP 90/60
- B. Chest pain
- C. Increased anxiety
- D. Temp 98.6°F
Correct Answer: B
Rationale: Chest pain is a hallmark of cardiogenic shock due to myocardial ischemia, distinguishing it from anaphylactic shock, which typically involves urticaria or bronchospasm. Low BP (A) and anxiety (C) are common in both, and normal temperature (D) is nonspecific.
The nurse is formulating a plan of care for a client with a goiter. The priority nursing diagnosis for the client with a goiter is:
- A. Body image disturbance related to enlargement of the neck
- B. Activity intolerance related to fatigue
- C. Nutrition imbalance, less than body requirements, related to increased metabolism
- D. Risk for ineffective airway clearance related to pressure of goiter on the trachea
Correct Answer: D
Rationale: A large goiter can compress the trachea, posing a risk for ineffective airway clearance, which is a priority due to its potential to impair breathing.
An obstetrical client is admitted in active labor. During examination,the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?
- A. Document the finding
- B. Report the finding to the physician
- C. Prepare the client for a C-section
- D. Continue primary care as prescribed
Correct Answer: B
Rationale: A papular lesion on the perineum during labor could indicate an infectious condition (e.g. herpes simplex virus) which poses risks to the newborn. Reporting to the physician is the most appropriate initial action to determine management such as the need for a C-section.
Which of the following describes the language development of a two-year-old?
- A. Doesn't understand yes and no
- B. Understands the meaning of all words
- C. Can combine three or four words
- D. Repeatedly asks 'why?'
Correct Answer: C
Rationale: A two-year-old typically can combine three or four words to form simple sentences (e.g., 'Me want milk'). They understand basic concepts like 'yes' and 'no,' but not all words. Repeatedly asking 'why?' is more common in older preschoolers.