What Apgar score should a nurse document for a newborn with a pink trunk and head, bluish hands and feet, flexed extremities 5 min after delivery, a weak and slow cry, a heart rate of 130/min, and cries in response to suctioning?
7
8
9
10
The Correct Answer is B
Choice A rationale
An Apgar score of 7 is considered fairly low and would typically be associated with a newborn who has more significant health concerns.
Choice B rationale
An Apgar score of 8 is considered to be within the normal range. This score would be consistent with a newborn who has a pink trunk and head, bluish hands and feet, flexed extremities, a weak and slow cry, a heart rate of 130/min, and cries in response to suctioning.
Choice C rationale
An Apgar score of 9 is considered to be within the normal range. However, given the newborn’s weak and slow cry, an Apgar score of 9 would be less likely.
Choice D rationale
An Apgar score of 10 is very unusual, as almost all newborns lose 1 point for blue hands and feet, which is normal for after birth.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
The deltoid muscle is not typically used for intramuscular injections in infants due to its small size.
Choice B rationale
The vastus lateralis muscle is one of the preferred sites for intramuscular injections in infants, including the vitamin K injection. This muscle is large enough to absorb the medication, and injections here carry less risk of hitting a nerve or blood vessel.
Choice C rationale
The ventrogluteal muscle is not typically used for intramuscular injections in infants. This site is often used in older children and adults.
Choice D rationale
The dorsogluteal site is not recommended for intramuscular injections due to the risk of damaging the sciatic nerve.
Correct Answer is C
Explanation
Choice A rationale
Slowing the client’s rate of breathing would not directly address the issue of strong, frequent contractions and uniform decelerations of the fetal heart rate. These symptoms suggest uterine hyperstimulation, which can compromise fetal oxygenation.
Choice B rationale
Increasing the rate of infusion of the IV oxytocin would likely exacerbate the problem, as oxytocin can cause uterine hyperstimulation, leading to reduced fetal oxygen supply.
Choice C rationale
Discontinuing the infusion of the IV oxytocin is the appropriate action. The pattern of contractions and fetal heart rate decelerations suggest uterine hyperstimulation, which can be caused by excessive oxytocin. Stopping the oxytocin infusion can help to normalize the contraction pattern and improve fetal oxygenation.
Choice D rationale
Decreasing the rate of infusion of the maintenance IV solution would not directly address the issue of uterine hyperstimulation and fetal heart rate decelerations.
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