A nurse observes that a newborn has a pink trunk and head, bluish hands and feet, and flexed extremities 5 min after delivery.
He has a weak and slow cry, a heart rate of 130/min, and cries in response to suctioning. The nurse should document what APGAR Score for this infant?
5.
6.
7.
8.
8.
The Correct Answer is C
Choice A rationale
An APGAR score of 5 indicates significant distress and poor adjustment to extrauterine life, which is not consistent with the provided description of the infant's condition.
Choice B rationale
An APGAR score of 6 suggests moderate difficulty with extrauterine adaptation, which is still not entirely consistent with the overall assessment of the infant.
Choice C rationale
An APGAR score of 7 aligns with the described observations of the newborn: pink trunk and head, bluish extremities, active movement, heart rate of 130/min, and a response to
suctioning, which suggest the infant is in reasonably good condition with some minor issues that need monitoring.
Choice D rationale
An APGAR score of 8 would indicate that the newborn is in very good condition with only slight adjustments needed, which does not fully match the infant's description with the noted
issues like a weak cry and bluish extremities.
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Correct Answer is D
Explanation
Choice A rationale
Examining the tympanic membrane at the beginning may cause distress to the child and make the rest of the exam difficult.
Choice B rationale
Before auscultating the chest and abdomen, the child needs to be calm and cooperative, which might not be the case if their ear is examined first.
Choice C rationale
Examining the tympanic membrane before the head and neck could lead to increased anxiety and uncooperativeness in the child during the rest of the exam.
Choice D rationale
Examining the tympanic membrane at the end allows for a more accurate and complete examination without causing the child to become distressed early in the process.
Correct Answer is A
Explanation
Choice A rationale
It is common for children who are hospitalized to regress temporarily in their behavior, including toilet training. Stress, unfamiliar environments, and illness can contribute to this regression. Assuring the parents that the child’s skills will return when they feel better helps alleviate their concerns.
Choice B rationale
Asking why it bothers the parent that their child has wet the bed may come across as insensitive or confrontational. It does not provide support or reassurance to the parent.
Choice C rationale
Telling the parent not to worry about the child wetting the bed because the child did not seem upset dismisses the parent’s feelings and does not address the underlying issue of the child’s regression.
Choice D rationale
Sharing personal experiences and saying it doesn’t bother the nurse may seem empathetic but does not provide the professional reassurance and support the parents need. It shifts the focus to the nurse rather than addressing the parents' concerns.