The nurse is calculating the one-minute Apgar score for a newborn infant and determines that the heart rate is 150 beats/minute, a vigorous cry is present, muscle tone is good with total flexion, quick reflex irritability noted, and skin color is dusky and cyanotic.

Which Apgar score should the nurse assign to this infant?

(Enter numeric value only.)

Answer and Explanation

The Correct Answer is ["9"]

To determine the Apgar score for the newborn infant, we assess five parameters: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Each parameter is scored from 0 to 2, with 2 being the highest score. Let's evaluate each parameter:

Heart rate: 150 beats/minute --> Score of 2.
Respiratory effort: Vigorous cry present --> Score of 2.
Muscle tone: Good muscle tone with total flexion --> Score of 2.
Reflex irritability: Quick reflex irritability noted --> Score of 2.
Color: Dusky and cyanotic skin color --> Score of 1.

Now, we sum up the scores: 2+2+2+2+1=92+2+2+2+1=9

Therefore, the Apgar score for this infant is 9.

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Correct Answer is C

Explanation

A. Firm, larger, and very tender to touch. This option describes the characteristics of engorged breasts, which typically occur a few days after birth as milk production increases and the breasts become full. Engorged breasts can feel firm, swollen, and tender to the touch due to the increased blood flow and milk accumulation. However, on the first postpartum day, engorgement may not yet be fully developed.

B. Soft, with no change from before delivery. This option is unlikely as the breasts typically undergo changes during the postpartum period, especially with the initiation of lactation. Soft breasts with no change from before delivery would not be expected on the first postpartum day.

C. Filling and secreting colostrum. This option is the most likely finding on the first postpartum day. Colostrum, the early milk produced by the breasts, begins to be secreted during the late stages of pregnancy and continues after birth. On the first postpartum day, the breasts may be filling with colostrum, which is typically thicker and more concentrated than mature breast milk. It is produced in small amounts, about 40-50ml on the first day but that is all an infant normally needs at this time.

D. Slightly firm with immediate let-down response. While some firmness may be present due to the initiation of lactation, an immediate let-down response is less likely on the first postpartum day. The let-down reflex, which triggers the release of milk from the breast, may take some time to establish and may not occur immediately after delivery.

A. Eats less salt-cured meats. B. Participates in healing rituals. C. Uses herbal remedies. D. Meditates in sweat lodges.

Correct Answer is C

Explanation

A. Eats less salt-cured meats: Reducing the intake of salt-cured meats is generally a positive behaviour, especially for someone with hypertension. This behaviour aligns with dietary recommendations for managing high blood pressure.

B. Participates in healing rituals: Healing rituals are part of many cultural practices and can provide emotional and spiritual support. However, without further information, it's unclear if these rituals interfere with the prescribed treatment. This may warrant additional assessment to ensure they complement the medical regimen.

C. Uses herbal remedies: The use of herbal remedies could potentially interact with prescribed antihypertensive medications. This behaviour requires careful assessment to ensure there are no harmful interactions or adverse effects on the treatment plan.

D. Meditates in sweat lodges: Sweat lodges are a traditional practice for many Native Americans, providing physical and spiritual cleansing. However, the high temperatures and dehydration risks associated with sweat lodges could adversely affect blood pressure control and overall cardiovascular health. This behaviour requires further evaluation to ensure it is safe for the client with hypertension.

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Naxlex Comprehensive Predictor Exams

On the first postpartum day, the nurse examines the breasts of a new mother. Which condition is the nurse most likely to find?

Correct Answer is C

Explanation

An older Native-American client with hypertension presents to an outpatient clinic for follow-up evaluation after initiation of treatment with oral antihypertensive medications. Report of which client behavior requires additional assessment by the nurse?

Correct Answer is C

Explanation

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