The nurse is caring for an infant delivered one minute ago. The infant has no spontaneous respirations, no response to stimulus, is limp, pale, and has a heart rate of 99 beats per minute.

How will the nurse document this infant's APGAR Score?

Enter number only (no units).

Answer and Explanation

The Correct Answer is ["1"]

The APGAR score assesses five criteria: Appearance (skin colour), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration (breathing effort). Each criterion is scored from 0 to 2, with a maximum total score of 10.

Appearance: The infant is pale, which scores 0.
Pulse: The heart rate is 99 beats per minute, which scores 1 (as it is below 100).
Grimace: No response to stimulus, which scores 0.
Activity: The infant is limp, which scores 0.
Respiration: No spontaneous respirations, which scores 0.

Summing these scores gives a total APGAR score of 1.

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Correct Answer is ["C","D","E"]

Explanation

Choice A reason: Placing the patient in a supine position is not recommended in cases of suspected partial placental abruption. The supine position can compress the inferior vena cava, reducing blood flow to the placenta and potentially worsening the condition. Instead, a lateral position is generally preferred to enhance blood flow.

Choice B reason: Encouraging oral intake is not a priority action in this scenario. In cases of suspected placental abruption, the patient may need to undergo emergency medical procedures, and maintaining an empty stomach is often advised to prevent aspiration if anaesthesia is required.

Choice C reason: Administering IV fluids is crucial in managing suspected partial placental abruption. This intervention helps maintain maternal blood pressure and ensures adequate blood flow to the placenta, which is essential for fatal well-being. IV fluids can also be vital in managing any potential blood loss.

Choice D reason: Evaluating fatal heart rate monitoring is essential to assess the foetus’s well-being. Continuous monitoring allows the healthcare team to detect any signs of fatal distress, which can guide further medical interventions and decision-making processes.

Choice E reason: Monitoring maternal pain is a critical component of managing suspected partial placental abruption. Pain assessment helps determine the severity of the abruption and the effectiveness of pain management strategies. It also provides valuable information about the patient's condition and the need for additional interventions.

A. Feeding the baby while lying in the bassinet B. Periodically pausing the feeding C. Discarding the remaining milk after one hour D. Holding the baby upright during feedings

Correct Answer is A

Explanation

Choice A reason: Feeding the baby while lying in the bassinet can pose a significant risk of choking and improper feeding technique. Babies should be fed while being held in an upright or semi-upright position to ensure proper swallowing and to prevent aspiration of milk into their airways. This practice promotes bonding between the caregiver and the baby and supports the baby’s overall feeding development. Therefore, further teaching is required for parents who feed their baby while the baby is lying in the bassinet.

Choice B reason: Periodically pausing the feeding is actually a recommended practice as it allows the baby to burp and prevents overfeeding. It also gives the baby a break to catch their breath and reset their sucking pattern. This technique can reduce the risk of discomfort and gas. Hence, this behaviour does not require further teaching.

Choice C reason: Discarding the remaining milk after one hour is a proper practice because milk can spoil and become contaminated with bacteria, leading to potential health risks for the baby if consumed. It is important to ensure that the baby is fed with fresh milk to avoid any health issues. Therefore, this behaviour does not require further teaching.

Choice D reason: Holding the baby upright during feedings is a correct and recommended practice. This position helps to prevent ear infections, reduces the risk of choking, and promotes better digestion. It ensures that the milk flows steadily and safely into the baby's mouth, aiding in a more efficient feeding process. Thus, this behaviour does not require further teaching.

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The nurse is caring for an infant delivered one minute ago. The infant has no spontaneous respirations, no response to stimulus, is limp, pale, and has a heart rate of 99 beats per minute. How will the nurse document this infant's APGAR Score? Enter number only (no units).

Nursing Test Bank

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Correct Answer is A

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The nurse is caring for an infant delivered one minute ago. The infant has no spontaneous respirations, no response to stimulus, is limp, pale, and has a heart rate of 99 beats per minute.

How will the nurse document this infant's APGAR Score?

Enter number only (no units).