You're assessing the one-minute APGAR score of a newborn baby. On assessment, you note the following about your newborn patient: weak cry, some flexion of the arm and legs, active movement and cries to stimulation, heart rate 145, and pallor all over the body and extremities. What is your patient's APGAR score?

APGAR 4

APGAR 6

APGAR 10

APGAR 9

Answer and Explanation

The Correct Answer is B

A.   A score of 4 would indicate severe distress, but the baby in this scenario shows signs of responsiveness and activity.
B.   A score of 6 suggests moderate adaptation to extrauterine life, considering some components of the APGAR are within the normal range.
C. A score of 10 is perfect, but the noted symptoms suggest some difficulties.
D.   A score of 9 would be high and not consistent with the observed signs of distress.

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Correct Answer is C

Explanation

A. Changing the perineal pad of a client who has just been transferred from the labor ward is a task that should not be delegated to an assistive personnel (AP) since it is beyond their scope.
B. Monitoring vital signs during the admission of a client with gestational hypertension requires nursing judgment and assessment skills.
C. Providing a sitz bath to a client with a fourth-degree laceration and is 2 days post- partum can be delegated to an AP. This task does not require the nurse's clinical judgment or assessment skills, and it can be safely performed by the AP following the nurse's instructions.
D. Observing an area of redness on the breast requires nursing assessment and intervention.

A. Wearing a loose-fitting bra to prevent nipple irritation. B. Express small amounts of milk from the breasts to relieve the pressure. C. Run warm water on her breasts during a shower. D. Apply ice to the breasts for comfort.

Correct Answer is D

Explanation

A. Wearing a loose-fitting bra may provide comfort but does not address the underlying issue of engorgement.
B. Expressing small amounts of milk may stimulate further milk production and is not recommended in cases of bottle-feeding.
C. Running warm water on the breasts may increase blood flow and exacerbate swelling.
D. Cold compresses or ice are more appropriate for relieving discomfort and reducing swelling.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

Correct Answer is C

Explanation

A woman gave birth 48 hours ago to a healthy infant girl. She has decided to bottle feed. During the assessment, the nurse notices that both breasts are swollen, warm, and tender on palpation. Which guidance should the nurse provide to the client at this time?

Correct Answer is D

Explanation

What are the most common causes for subinvolution of the uterus?

A nurse is caring for a client who is 6 hours postpartum and asks the nurse to feed her newborn. Which of the following responses should the nurse provide?

A nurse is providing discharge teaching to a client who is 3 days postoperative following a cesarean birth. Which of the following client statements indicates to the nurse that further teaching is needed??

A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action?

A nurse is reinforcing teaching about reducing perineal infection with a client following a vaginal delivery. Which of the following should the nurse include in the teaching? (Select all that apply.)

A nurse is caring for a client who is postpartum who asks the nurse when her breast milk will "come in." Which of the following responses should the nurse make?

A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?