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
Negative behaviors characterized by the need for autonomy are typical of toddlers. According to Erikson, this stage is known as autonomy versus shame and doubt, where toddlers
assert their independence and develop self-control.
Choice B rationale
Erikson's stage of initiative versus guilt applies to preschool children, not toddlers. This stage involves children beginning to assert power and control over their environment through
directing play and other social interactions.
Choice C rationale
The need to start a task and complete it is associated with Erikson's stage of industry versus inferiority, which applies to school-aged children, not toddlers. This stage involves
developing a sense of pride in their accomplishments.
Choice D rationale
The discovery of their identity is a characteristic of Erikson's stage of identity versus role confusion, which pertains to adolescence. During this stage, teenagers work on refining a
sense of self.