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Showing 18 questions, Sign in for moreA nurse is present during the delivery of a healthy term newborn. The baby is delivered vaginally and does not require any resuscitation efforts. One minute after birth, the nurse assesses the newborn using the Apgar score. The nurse finds the following: Makes a strong cry, Pulse (heart rate): 120 beats per minute (bpm), Pink all over, Active movement, Deep, regular breaths.
What is the MOST likely Apgar score for this newborn?
A nurse is caring for a newborn who has an Apgar score of 8 at one minute after birth and an Apgar score of 10 at five minutes after birth.
Which statement best describes this newborn’s condition?
A nurse is teaching a class on Apgar scoring to nursing students. Which statement by a student indicates a need for further teaching
A nurse is assessing a newborn's gestational age using the New Ballard Scale.
Which of the following signs would indicate prematurity?
A client asks the nurse about the purpose of the New Ballard Scale.
How should the nurse respond?
A nurse is performing the physical maturity test on a newborn using the New Ballard Scale.
What characteristic would the nurse assess?
A nurse palpates an infant’s anterior fontanelle and notes that it feels soft and flat when lying down, but slightly elevated when sitting up or crying.
What should be included in documentation?
A nurse observes that an infant has an elongated head shape due to molding during delivery.
The nurse explains to the parents that this condition is called:
A nurse is caring for an infant who has a cephalohematoma on the left side of his skull.
Which of the following interventions should the nurse implement?
A nurse is assessing an older adult client’s mouth.
The nurse should identify that which of the following is an expected variation for this client?
A nurse is preparing to assess a client’s conjunctiva.
Identify the sequence the nurse should follow when taking the following actions.
1) Apply examination gloves.
2) Instruct the client to look up.
3) Place the thumbs below each of the client’s lower eyelids.
4) Gently pull the client’s skin down to the top edge of the bony orbital rim.
5) Inspect the color and condition of the conductive and sclera, noting any color change, swelling, drainage, or lesions.
A nurse is caring for a client who reports that he has a headache and vertigo after turning on his furnace for the first time this season.
The nurse suspect which of the following?
A nurse is preparing to administer erythromycin ointment to a newborn’s eyes as prophylaxis for gonorrhea and chlamydia infections.
Which of the following actions should the nurse take?
A nurse is caring for a newborn who has hyperbilirubinemia and is receiving phototherapy.
Which of the following interventions should the nurse implement?
A nurse is reviewing laboratory results for a newborn who was born to a mother who has type O positive blood and tested negative for hepatitis B surface antigen (HBsAg).
The newborn has type A positive blood and tested positive for Coombs antibody (anti-A).
Which of the following actions should the nurse take?
A nurse is performing a head-to-toe assessment of a newborn.
What finding should alert the nurse to a potential problem with the newborn’s fontanelles?
A nurse is supporting bonding and attachment between parents and their newborn.
What intervention should the nurse implement to promote skin-to-skin contact?
Select all that apply.
A nurse is providing comfort measures to a newborn during an assessment.
What non-pharmacological interventions can the nurse use to soothe the newborn?
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