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.".
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Blood pressure of 136/88 mm Hg should be monitored, but it is not a finding that the nurse needs to urgently report to the provider following the administration of butorphanol. The blood pressure reading is slightly elevated but might be attributed to pain or anxiety during labor.
Choice B rationale:
Moderate fetal heart rate variability is a reassuring sign of fetal well-being and is an expected finding during labor. It does not require immediate reporting to the provider.
Choice C rationale:
Respiratory rate of 100/min is significantly increased and should be reported to the provider following the administration of butorphanol. Respiratory depression is a potential side effect of opioids like butorphanol, and a respiratory rate of 100/min raises concern for potential respiratory compromise.
Choice D rationale:
Urinary output of 120 mL in 2 hours is an acceptable finding during labor and does not require immediate reporting to the provider. Adequate urinary output varies, but generally, 30 mL/hour is considered acceptable during labor.
Correct Answer is C
Explanation
Listeriosis is a foodborne illness that can have severe consequences during pregnancy. To minimize the risk of listeriosis, a pregnant client should avoid certain foods that are more likely to be contaminated with the bacteria Listeria. The correct statement that indicates an understanding of the teaching is:
C) "I can eat grilled chicken on a bun at lunchtime."
Grilled chicken is a safe option, and as long as it's properly cooked, it's a suitable choice during pregnancy. The other options are not recommended during pregnancy:
A) Soft cheeses, like Brie or feta, can carry a risk of Listeria contamination, so they should be avoided.
B) Seafood salad from the grocery store may not be safe as it could contain seafood that's been sitting at improper temperatures, which can increase the risk of foodborne illness.
D) Hot dogs can also be a risk as they are often not served steaming hot, which is necessary to kill any potential Listeria contamination.
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