A nurse is teaching a class on Apgar scoring to nursing students. Which statement by a student indicates a need for further teaching
“If a newborn has a heart rate below 100 beats per minute, he will receive one point for heart rate.”
“If a newborn has acrocyanosis, he will receive one point for color.”
“If a newborn has active motion of extremities, he will receive two points for muscle tone.”
“If a newborn has a vigorous cry when stimulated, he will receive two points for reflex irritability.”.
The Correct Answer is B
This is wrong because acrocyanosis means that the body is pink but the extremities are blue, which indicates poor circulation. A normal Apgar score for color is two points, which means that the baby is pink all over.
Choice A is correct because a heart rate below 100 beats per minute is considered moderately abnormal and receives one point.
Choice C is correct because active motion of extremities indicates good muscle tone and receives two points.
Choice D is correct because a vigorous cry when stimulated indicates good reflex irritability and receives two points.
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Correct Answer is D
Explanation
Plagiocephaly.
This condition is also known as flat head syndrome and it occurs when an infant’s head shape becomes flattened due to external pressure.It can be caused by molding during delivery or by sleeping in the same position for a long time.
Choice A is wrong because caput succedaneum is a swelling of the scalp that results from pressure on the baby’s head during childbirth.It does not affect the shape of the head, but only causes temporary puffiness and bruising.
Choice B is wrong because cephalohematoma is bleeding under the scalp that occurs when blood vessels are damaged during delivery.It causes a firm lump on one side of the head that does not cross the suture lines.
Choice C is wrong because craniosynostosis is a condition where one or more of the sutures (joints) between the skull bones close prematurely, preventing normal growth of the head.It can cause an abnormal head shape, but it is not related to molding during delivery.
Correct Answer is A
Explanation
The nurse should follow the sequence of 1, 2, 3, 4, 5 when assessing the client’s conjunctiva.This is because the nurse should first apply examination gloves to prevent contamination and infection.Then, the nurse should instruct the client to look up to expose the lower eyelid and conjunctiva.Next, the nurse should place the thumbs below each of the client’s lower eyelids and gently pull the skin down to the top edge of the bony orbital rim.This allows the nurse to inspect the color and condition of the conjunctiva and sclera, noting any color change, swelling, drainage, or lesions.The sclera should be white and the conjunctiva should be pink.
Choice B is wrong because the nurse should not pull down the skin before instructing the client to look up.
This could cause discomfort and injury to the eye.
Choice C is wrong because the nurse should not instruct the client to look up after pulling down the skin.
This could also cause discomfort and injury to the eye.
Choice D is wrong because the nurse should not place the thumbs below each of the client’s lower eyelids before applying examination gloves.
This could introduce infection and irritants to the eye.
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