Nokea
You are caring for a patient who just gave birth to a 6 lb. 13 oz. baby boy. The infant gave out a lusty cry, had a pink coloration all over his body, had flexed arms and legs, cried when stimulated, and had a pulse rate of 94. What Apgar score would you expect for this baby?
- A. 10
- B. 8
- C. 7
- D. 9
Correct Answer: D
Rationale: The Apgar score is a method used to quickly assess the health of newborns. In this scenario, the baby would receive 2 points for color, reflex irritability, and muscle tone, but only 1 point for a pulse rate of 94, resulting in an Apgar score of 9. An Apgar score of 9 indicates that the baby is in good health overall. Choice A (10) is incorrect because a pulse rate of 94 would only score 1 point. Choices B (8) and C (7) are incorrect as the given criteria would lead to a higher score, indicating the baby's good health.
You may also like to solve these questions
A female client who has been taking oral contraceptives for the past year comes to the clinic for an annual exam. Which finding is most important for the PN to report to the HCP?
- A. Breast tenderness
- B. Change in menstrual flow
- C. Left calf pain
- D. Weight gain of 5 pounds
Correct Answer: C
Rationale: Left calf pain could indicate deep vein thrombosis (DVT), a serious side effect of oral contraceptives. Reporting this finding to the healthcare provider is critical for further evaluation and treatment. Breast tenderness and change in menstrual flow are common side effects of oral contraceptives and may not be as urgent as left calf pain. Weight gain of 5 pounds, while noteworthy, is not as concerning as a possible indication of DVT.
A child with glomerulonephritis is admitted in the acute edematous phase. Based on this diagnosis, which nursing intervention should the PN plan to include in the child's plan of care?
- A. Recommend parents bring favorite snacks
- B. Encourage ambulation daily to the playroom
- C. Measure blood pressure every 4 to 6 hours
- D. Offer a selection of fresh fruit for each meal
Correct Answer: C
Rationale: The correct answer is to measure blood pressure every 4 to 6 hours. In glomerulonephritis, monitoring blood pressure is crucial as hypertension is a common complication. This helps in assessing the child's condition and response to treatment. Choice A, recommending parents bring favorite snacks, is not related to managing glomerulonephritis. Choice B, encouraging ambulation daily to the playroom, may not be appropriate during the acute edematous phase when the child may be experiencing fluid overload. Choice D, offering a selection of fresh fruit for each meal, is not directly relevant to managing the complications of glomerulonephritis.
What is the primary purpose of performing range-of-motion (ROM) exercises?
- A. To improve cardiovascular fitness
- B. To prevent muscle atrophy and joint contractures
- C. To increase respiratory function
- D. To enhance cognitive function
Correct Answer: B
Rationale: The primary purpose of performing range-of-motion (ROM) exercises is to prevent muscle atrophy and joint contractures. These exercises are crucial in maintaining joint mobility and muscle flexibility, especially in patients who are immobilized or have limited mobility. Improving cardiovascular fitness (Choice A) involves different types of exercises that target the heart and blood vessels, not specifically ROM exercises. Increasing respiratory function (Choice C) is typically achieved through breathing exercises and activities that enhance lung capacity. Enhancing cognitive function (Choice D) is usually addressed through cognitive exercises and activities that stimulate brain function.
Which type of isolation precaution is required for a patient with tuberculosis (TB)?
- A. Droplet precautions
- B. Contact precautions
- C. Airborne precautions
- D. Standard precautions
Correct Answer: C
Rationale: The correct answer is C: Airborne precautions. Tuberculosis (TB) is transmitted via airborne particles, thus requiring airborne precautions to prevent the spread of infection. This includes using an N95 respirator to filter out small infectious particles. Droplet precautions (Choice A) are used for diseases that spread through large respiratory droplets. Contact precautions (Choice B) are for direct or indirect contact with the patient or their environment. Standard precautions (Choice D) are used for all patients to prevent the spread of infection through blood, bodily fluids, non-intact skin, and mucous membranes.
A 12-year-old child is receiving a blood transfusion via an infusion pump and begins to complain of 'itchy' skin 15 minutes after the unit of blood is started. The child appears flushed. What action should the nurse take first?
- A. Apply lotion to the skin
- B. Stop the transfusion
- C. Inspect the infusion site
- D. Obtain the vital signs
Correct Answer: B
Rationale: Stopping the transfusion immediately is crucial when signs of a transfusion reaction, such as itching and flushing, occur. This action is taken to prevent further exposure to the potentially harmful transfused blood. Applying lotion to the skin, inspecting the infusion site, or obtaining vital signs can be important but are secondary to stopping the transfusion to ensure the safety of the child. Applying lotion may not address the underlying issue of a possible transfusion reaction. Inspecting the infusion site and obtaining vital signs can be done after stopping the transfusion, as patient safety is the top priority in this situation.