A nurse is assisting in the care of a newborn following birth. At 1 min after birth, the nurse notes the following: heart rate 110/min; slow, weak cord flexion of extremities; grimace in response to suctioning of the nares; body pink in color with blue extremities.

What should the nurse document as the newborn's 1-min Apgar score?
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Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B"}

The Apgar score is a scoring system used by doctors and nurses to assess newborns one minute and five minutes after they are born. The score is based on five criteria: activity, pulse, grimace, appearance, and respiration, with each criterion receiving a score of 0 to 2 points.

If we apply this scoring system to the information provided, the newborn's 1- minute Apgar score would be:

Activity: 1 point (limbs flexed)

Pulse: 1 point (heart rate less than 100 beats per minute) Grimace: 1 point (facial movement/grimace with stimulation) Appearance: 1 point (body pink but extremities blue) Respiration: 1 point (irregular, weak crying)

The total score is 5 points, which is considered moderately abnormal.

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Correct Answer is A

Explanation

Massage the fundus. This is because massaging the fundus (the upper part of the uterus) can help the uterus contract and prevent excessive bleeding after delivery. A soft, boggy uterus indicates uterine atony, which is a failure of the uterus to contract sufficiently after childbirth.

Uterine atony is the most common cause of postpartum hemorrhage, which can be life-threatening if not treated promptly¹².

Choice B is not correct because initiating measures that encourage voiding is not the appropriate intervention for a soft, boggy uterus. A full bladder can interfere with uterine contractions and cause bleeding, so it is important to empty the bladder after delivery. However, this should be done after massaging the fundus.

Choice C is not correct because positioning the patient flat is not the appropriate intervention for a soft, boggy uterus. Positioning the patient flat can increase blood loss and reduce venous return. The patient should be positioned with the head slightly elevated and the legs flexed to improve blood circulation and prevent shock³.

Choice D is not correct because notifying the doctor is not the first intervention for a soft, boggy uterus. Notifying the doctor is important if bleeding persists or worsens despite massaging the fundus. The doctor may order medications or other treatments to stop the bleeding and prevent complications¹.

A. Hypotension B. Cold, clammy skin C. Tachycardia D. Decreased urinary output

Correct Answer is C

Explanation

Tachycardia. Tachycardia is a sign of hypovolemic shock from postpartum hemorrhage, which occurs when the blood volume is reduced and the heart rate increases to compensate for the low cardiac output and tissue perfusion. Tachycardia is usually the first sign of hypovolemic shock, as it can occur even before a significant drop in blood pressure or other symptoms.

Choice A. Hypotension is incorrect because it is a late sign of hypovolemic shock, which occurs when the compensatory mechanisms fail to maintain adequate blood pressure and organ perfusion.

Choice B. Cold, clammy skin is incorrect because it is a sign of peripheral vasoconstriction, which occurs as a compensatory mechanism to divert blood flow to the vital organs. However, it is not specific to hypovolemic shock and can occur in other types of shock as well.

Choice D. Decreased urinary output is incorrect because it is a sign of renal impairment, which occurs as a result of reduced blood flow to the kidneys. However, it is not specific to hypovolemic shock and can occur in other types of shock or renal disorders as well.

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Naxlex Comprehensive Predictor Exams

Following delivery, the nurse's assessment reveals a soft, boggy uterus located above the level of the umbilicus. The appropriate intervention is:

Correct Answer is A

Explanation

The first sign of hypovolemic shock from postpartum hemorrhage is likely to be:

Correct Answer is C

Explanation

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