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 A

Explanation

A. The priority is to assess the client's uterine fundus to determine if it is well-contracted. Excessive bleeding could be indicative of uterine atony, and prompt assessment is crucial for intervention.
B. Assisting the client on a bedpan to urinate is a secondary intervention. While a distended bladder can contribute to uterine atony, assessing the fundus comes first to determine the cause.
C. Increasing fluid intake is important for postpartum recovery, but it is not the immediate priority in this situation.
D. Preparing to administer oxytocic medication may be necessary if uterine atony is identified during the fundal assessment. However, assessing the fundus comes first to guide appropriate interventions.

A. “Wash your hands before touching the newborn" B. "All client identification bands should remain in place until discharge." C. "Do not let anyone remove the infant from your sight while you are in the hospital." D. "Check the identification of staff, and if there is a question of validity, call the nursing station." E. "Send the newborn to nursery to be monitored during the night."

Correct Answer is ["A","B","C","D"]

Explanation

A. Hand hygiene is crucial to prevent the spread of infections to the newborn.

B. Keeping identification bands on ensures proper identification of the newborn.

C. Keeping the infant within sight reduces the risk of abduction.

D. Verifying staff identification enhances security and prevents unauthorized individuals from handling the newborn.
E. Sending the newborn to the nursery at night may compromise the mother-infant bonding and is not a recommended practice.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period. Which of the following is the priority nursing intervention at this time?

Correct Answer is A

Explanation

A mother and her newborn have just been transferred to the postpartum unit from labor and delivery. Which infant safety education would be provided as soon as mom and baby are settled into their room? Select all that apply. One, some, or all responses may be correct.

Correct Answer is ["A","B","C","D"]

Explanation

A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take?

Which documentation on a woman's chart on postpartum day 14 indicates a normal involution process?

A nurse is caring for a client who is postpartum. The client tells the nurse that the newborn’s maternal grandmother was born deaf and asks how to tell if her newborn hears well. Which of the following statements should the nurse make?

A nurse is assisting with the care of a newborn immediately following birth. Which of the following medications should the nurse anticipate administering? (Select all that apply.)

Nurses play a critical role in educating parents regarding measures to prevent infant abduction. Which instructions contribute to infant safety and security?

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?

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?