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:
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.
Correct Answer is C
Explanation
Choice A rationale:
The nurse should not apply lotion to the newborn's skin during phototherapy. Phototherapy involves exposing the newborn's skin to light to treat jaundice by breaking down bilirubin. Applying lotion may interfere with the effectiveness of the therapy and may not be recommended as it can make it difficult for the skin to release heat generated during the process.
Choice B rationale:
Giving the newborn glucose water every 4 hours is not a necessary action during phototherapy. The primary concern during phototherapy is to treat jaundice, and giving glucose water may not have a direct impact on the effectiveness of the treatment. Additionally, it is important to focus on monitoring the newborn's bilirubin levels and hydration status.
Choice D rationale:
Dressing the newborn in a thin layer of clothing during phototherapy is not recommended. Phototherapy works best when the newborn's skin is exposed to a light source, and covering the skin with clothing may decrease the effectiveness of the treatment.
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