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A nurse is teaching a newly hired nurse about Apgar scoring. Which of the following statements by the newly hired nurse indicates an understanding of the teaching?

A.

"The nurse should determine the Apgar score at 2 and 7 minutes after birth.”.

B.

"The nurse should identify that the newborn is in severe distress with an Apgar score of 8.”.

C.

"The nurse should wait for the first Apgar score before initiating resuscitation efforts.”.

D.

"The nurse should measure the newborn's muscle tone when assigning an Apgar score.".

Answer and Explanation

The Correct Answer is D

 

The correct answer is choice d. “The nurse should measure the newborn’s muscle tone when assigning an Apgar score.”

 

Choice A rationale:

 The Apgar score is determined at 1 and 5 minutes after birth, not at 2 and 7 minutes.

 

Choice B rationale:

 An Apgar score of 8 indicates that the newborn is in good health, not severe distress. Scores of 7-10 are considered normal.

 

Choice C rationale:

 Resuscitation efforts should not be delayed until the first Apgar score is obtained. Immediate resuscitation is initiated if needed, regardless of the Apgar score.

 

Choice D rationale:

 Muscle tone is one of the five criteria assessed in the Apgar score, along with appearance, pulse, grimace, and respiration.


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Related Questions

Correct Answer is D,C,B,A

Explanation

The correct sequence for suctioning a newborn with a bulb syringe, according to the information provided, is as follows: 1. Compress the bulb syringe (d) to expel the air. 2. Place the bulb syringe in the newborn’s mouth © to suction the mucus. 3. Use the bulb syringe to suction the newborn’s nose (b) after the mouth has been cleared. 4. Assess the newborn for reflex bradycardia (a) following the suctioning. This sequence ensures that the airway is cleared effectively and safely, minimizing the risk of inducing bradycardia by stimulating the vagus nerve during suctioning. Always remember to perform these steps gently and to follow the guidelines and protocols of your healthcare facility.

Correct Answer is C

Explanation

Choice Arationale:
Offering the client a sitz bath may provide some relief, but it does not address the underlying issue of bladder distention. The priority is to address the bladder distention directly.

Choice Brationale:
Inserting a urinary catheter is not the first-line intervention for bladder distention after vaginal birth. Catheterization carries a risk of infection and trauma, so it should only be done if other interventions are not effective.

Choice C rationale:
Assisting the client to the bathroom is the first action the nurse should take. Bladder distention can occur after birth due to the pressure on the bladder during labour and birth. Encouraging the client to empty her bladder will relieve the distention and promote comfort.

Choice D rationale:
Pouring warm water over the client's perineum might provide some comfort, but it does not address the bladder distention itself.

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