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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?

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

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

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

"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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Correct Answer is C

Explanation

Choice A rationale:

Scant, bright red spotting during early pregnancy can be a normal finding known as implantation bleeding, which occurs when the embryo attaches to the uterus. It is generally not a cause for concern unless it becomes heavy and is accompanied by severe pain.

Choice B rationale:

Elevated hCG (human chorionic gonadotropin) levels during the first trimester are a normal part of a healthy pregnancy. hCG levels peak around 10-12 weeks of gestation and then gradually decrease. A consistent increase in hCG levels is usually a positive sign of a progressing pregnancy.

Choice C rationale:

Cervical dilation during the first trimester, especially when the client is only at 12 weeks of gestation, is not normal and may indicate an imminent spontaneous abortion (miscarriage). This finding should be reported promptly to the healthcare provider for further assessment and management.

Choice D rationale:

Slight abdominal cramps can be a normal symptom during early pregnancy as the uterus undergoes changes and expands. However, unless they are severe and accompanied by other concerning signs such as heavy bleeding, they are not necessarily indicative of an imminent spontaneous abortion.

A. Incompetent cervix. B. Postpartum hemorrhage. C. Ectopic pregnancy. D. Hyperemesis gravidarum.

Correct Answer is B

Explanation

Choice A rationale:
The incompetent cervix is not related to the client's current situation. An incompetent cervix refers to a weakened cervix that may result in premature dilation during pregnancy, leading to potential pregnancy loss or preterm birth. It is not relevant to the client's current stage of labour and cervical dilation.

Choice B rationale:
Postpartum haemorrhage is the correct condition to be concerned about in this situation. The client is 80% effaced and 8 cm dilated, which indicates she is in active labour. These signs of progress indicate that she is at risk for excessive bleeding after delivery, which is known as postpartum haemorrhage.

Choice C rationale:
An ectopic pregnancy occurs when a fertilized egg implants outside the uterus, typically in the fallopian tube. This condition is not related to the client's current presentation, as she is already in active labour.

Choice D rationale:
Hyperemesis gravidarum is severe and persistent nausea and vomiting during pregnancy, usually during the first trimester. This condition is not relevant to the client's current situation, which involves active labour and cervical dilation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is at 12 weeks of gestation. The nurse should report which of the following findings to the provider as an indication of an imminent spontaneous abortion?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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