Question 1

At 1 minute after birth, the infant has a heart rate of 100 beats per minute, and is crying vigorously. The limbs are flexed, the trunk is pink, and the feet and hands are cyanotic. The infant cries easily when the soles of the feet are stimulated. How would the nurse document this infant's Apgar score?

Accepted Answer

The Apgar score is determined by evaluating the newborn on five simple criteria on a scale from zero to two, then summing up the five values thus obtained. The five criteria are Appearance (skin color), Pulse (heart rate), Grimace response (reflexes), Activity (muscle tone), and Respiration (breathing rate and effort). In this case, the infant would receive a score of 2 for heart rate (over 100 beats per minute), 2 for respiratory effort (crying vigorously), 2 for reflex irritability (cries easily when soles are stimulated), 2 for activity (limbs are flexed), and 1 for appearance (body pink but extremities cyanotic), totaling a score of 9.

Question 2

The neonate was born 5 minutes ago. The body is bluish. The heart rate is 150. The infant is crying strongly. The infant cries when the sole of the foot is stimulated. The arms and legs are flexed, and resist straightening. What should the nurse record as this infant's Apgar score?

Accepted Answer

The Apgar score is calculated based on five criteria: Appearance, Pulse, Grimace, Activity, and Respiration. Each is scored 0, 1, or 2. In this case: Appearance (1 for bluish body), Pulse (2 for heart rate >100), Grimace (2 for crying when stimulated), Activity (2 for flexed arms and legs), Respiration (2 for strong cry). Total score: 1+2+2+2+2 = 9.

Question 3

The nurse is observed performing the following with a patient:  What information will this assessment technique provide to the nurse?

Accepted Answer

The answer of The nurse is observed performing the following...

Question 4

A newborn has the following applied to the umbilical cord.  What should the nurse instruct the new parents about regarding this device?

Accepted Answer

The answer of A newborn has the following applied to...

Question 5

A young adolescent is transferred to the labor and delivery unit from the emergency department. The client is in active labor, but did not know she was pregnant. What is the most important nursing action?

Accepted Answer

Assessing blood pressure and checking for proteinuria are critical actions to identify preeclampsia, a potentially life-threatening condition for both the mother and baby. This assessment is a priority in ensuring the safety and health of the patient in labor, especially when the pregnancy was unknown and prenatal care may have been lacking.

Question 6

The nurse determines that a newborn has the following findings:
Heart rate: 88 beats per minute
Respirations: 24 per minute and irregular
Muscle tone: Minor movement of lower extremities
Reflex response: Grimace
Skin color: Pink body, blue extremities
If using the following table, what action should the nurse take at this time?
Table 21-5 The Apgar Scoring System

Accepted Answer

The answer of The nurse determines that a newborn has...

Question 7

As compared with admission considerations for an adult woman in labor, the nurse's priority for an adolescent in labor would be which of the following?

Accepted Answer

The nurse's priority for an adolescent in labor would be the developmental level. Adolescents may have different needs, understanding, and coping mechanisms due to their developmental stage compared to adult women. This consideration is crucial for providing appropriate care and support during labor.

Question 8

A client delivered 30 minutes ago. Which postpartal assessment finding would require close nursing attention?

Accepted Answer

A soaked perineal pad within such a short period indicates excessive bleeding, which is a sign of postpartum hemorrhage and requires immediate attention.

Question 9

Before applying a cord clamp, the nurse assesses the umbilical cord. The mother asks why the nurse is doing this. What should the nurse reply?

Accepted Answer

A normal umbilical cord has two arteries and one vein, which is what the nurse is checking for to ensure the baby's circulatory system was functioning properly in utero.

Question 10

An abbreviated systematic physical assessment of the newborn is performed by the nurse in the birthing area to detect any abnormalities. Normal findings would include which of the following?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Accepted Answer

A normal newborn should have a respiration rate of 30-60 breaths per minute, a temperature above 36.5°C (97.8°F), and sole creases that involve the heel. The skin color should not be blue, and the umbilical cord should have two arteries and one vein, not two veins and one artery.

Question 11

The nurse has completed an initial physical assessment for a client admitted to the birthing unit. Which action should the nurse take next?

Accepted Answer

The answer of The nurse has completed an initial physical...

Question 12

Upon delivery of the newborn, what nursing intervention most promotes parental attachment?

Accepted Answer

Placing the newborn on the mother's abdomen immediately after delivery promotes skin-to-skin contact, which is known to facilitate bonding and attachment between the parent and the newborn. This practice also supports the initiation of breastfeeding and helps regulate the newborn's temperature and heart rate.

Question 13

The nurse has taken a detailed social history from a client admitted to the birthing unit. Which insights may the nurse gain as a result of this assessment?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Accepted Answer

A detailed social history can provide insights into the client's social habits and psychological factors, which can affect their health and care needs.

Question 14

A client's labor has progressed so rapidly that a precipitous birth is occurring. What should the nurse do?

Accepted Answer

Staying with the client and asking auxiliary personnel for assistance is crucial during a precipitous birth to ensure both the mother's and baby's safety and to provide immediate care. Leaving the client or attempting to delay the birth could be harmful.

Quiz 21: The Family in Childbirth: Needs and Care

The neonate was born 5 minutes ago. The body is bluish. The heart rate is 150. The infant is crying strongly. The infant cries when the sole of the foot is stimulated. The arms and legs are flexed, and resist straightening. What should the nurse record as this infant's Apgar score?

The nurse is observed performing the following with a patient: What information will this assessment technique provide to the nurse?

A newborn has the following applied to the umbilical cord. What should the nurse instruct the new parents about regarding this device?