Nokea
What is nurse's primary critical observation when performing an assessment for determining an Apgar score?
- A. Heart rate
- B. Respiratory rate
- C. Presence of meconium
- D. Evaluation of Moro reflex
Correct Answer: A
Rationale: Apgar score assesses newborn vitality at 1 and 5 minutes post-birth across five criteria: heart rate, respiration, muscle tone, reflex, color. Heart rate (choice A) is primary; absent (<60 bpm = 0, <100 = 1, >100 = 2) dictates immediate resuscitation, making it the most critical. Respiratory rate (choice B) follows, but weak/absent breathing often ties to heart rate. Meconium (choice C) isn't scored directly, though it flags distress. Moro reflex (choice D) tests tone/reflex, secondary to vitals. A is correct, as heart rate drives initial intervention. Nurses prioritize it, ensuring rapid response to stabilize the infant.
You may also like to solve these questions
The nurse assesses a client at 40 weeks gestation and notes regular contractions and cervical dilatation of $6 \mathrm{~cm}$. Which actions by the nurse are important during this stage? Select all that apply.
- A. Administering the epidural injection
- B. Ensuring adequate hydration
- C. Encouraging the client to void
- D. Monitoring the condition of the fetus
Correct Answer: D
Rationale: At 40 weeks gestation with 6 cm cervical dilatation, the client is in active labor. Monitoring the fetus (D) is critical to assess for distress via heart rate patterns, a priority in labor management. Administering an epidural (A) requires an order and isn't universally needed. Ensuring hydration (B) supports labor but isn't the top action. Encouraging voiding (C) prevents bladder distension but is secondary. D is chosen. Rationale: Fetal monitoring detects hypoxia or distress, guiding interventions like position changes or delivery, per ACOG standards, outweighing comfort or supportive measures in immediacy during active labor.
Roger has been seen agitated, shouting and running. As Nurse Aida approaches, he shouts and swear, calling Aida names. Nurse Aida told Roger 'That is an unacceptable behavior Roger, Stop and go to your room now.' The situation is most likely in what phase of NPR?
- A. Pre Orientation
- B. Orientation
- C. Working
- D. Termination
Correct Answer: C
Rationale: This scenario fits the Working phase (C). Roger's agitation and Aida's response setting boundaries suggest an established relationship where interventions address behaviors. Pre-Orientation (A) is pre-contact, Orientation (B) builds trust, not confrontation, and Termination (D) ends care. In Peplau's Working phase, the nurse actively helps the client manage issues, as Aida does here, making C the likely phase.
Which of the following statement best describes blood pressure?
- A. It is the force exerted by the blood against the walls of the blood vessels
- B. The lowest pressure is called systolic pressure
- C. BP is controlled by the sympathetic nervous system alone
- D. BP is measured using sphygmomanometer on the forearm
Correct Answer: A
Rationale: Blood pressure is the force of blood against vessel walls (A), per its definition in physiology. Systolic is the highest pressure (B), not lowest false. BP involves sympathetic and parasympathetic systems (C), not just one. Sphygmomanometers measure at the upper arm, not forearm (D). A accurately captures BP's essence, validated by clinical practice, making it the best and correct description.
The parents of a healthy 6-year-old ask the nurse for advice about preventing obesity in their child. Which response reflects health promotion?
- A. Limit screen time and encourage outdoor play.'
- B. Weigh your child monthly to monitor for weight gain.'
- C. Give your child a multivitamin daily to prevent obesity.'
- D. Have your child's cholesterol checked annually.'
Correct Answer: A
Rationale: For a healthy 6-year-old, health promotion prevents obesity by fostering active habits limiting screen time and encouraging outdoor play boosts physical activity, burning calories and building muscle, key to avoiding weight gain at this age. Evidence links sedentary screen hours to childhood obesity; play counters it, aligning with nursing's focus on lifestyle over surveillance. Monthly weighing is secondary, tracking not preventing, and may stress the child. Multivitamins don't prevent obesity caloric balance does while annual cholesterol checks detect, not avert, issues. The nurse's reply promotes wellness through fun, practical steps like biking or tag tailored to a child's energy, ensuring long-term health without medicalizing a well kid, a cornerstone of pediatric nursing's preventive approach.
Which of the following statement is NOT true about cultural competence in nursing?
- A. Respects diversity
- B. Improves care
- C. Forces assimilation
- D. Adapts to patient needs
Correct Answer: C
Rationale: Cultural competence respects diversity (A), improves care (B), adapts (D) 'forces assimilation' (C) isn't true, opposes respect, per standards. C's coercion contradicts competence, like with Mr. Gary's beliefs, making it untrue.