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 B
Explanation
Choice A rationale
Placing a baby’s crib next to a heater can pose a risk of overheating or burns. Newborns should be kept at a safe distance from heaters to prevent accidents.
Choice B rationale
Removing extra blankets from the crib is recommended to reduce the risk of suffocation and sudden infant death syndrome (SIDS). This choice reflects an understanding of crib safety.
Choice C rationale
Padding the mattress can pose suffocation risks and is not recommended. A firm mattress without any padding is the safest option for newborns.
Choice D rationale
Placing a baby on their stomach to sleep increases the risk of SIDS. The recommended sleeping position for newborns is on their back, as this significantly reduces the risk.
Correct Answer is C
Explanation
Choice A rationale
Encouraging play exercises in the evening can lead to overstimulation, which can make it harder for the toddler to fall asleep. Physical activity should generally be done earlier in the day to help with sleep later on.
Choice B rationale
Turning off the room light can create a dark environment conducive to sleep, but it doesn’t address the need for a calming routine, which is essential for young children’s sleep. Some children also feel safer with a nightlight.
Choice C rationale
Providing bedtime rituals can help signal to the toddler that it is time to wind down and sleep. Consistent rituals, such as reading a story or singing a lullaby, provide a sense of security and comfort.
Choice D rationale
Explaining the source of the toddler’s fears may be beyond the cognitive ability of a toddler and does not directly promote sleep. It’s better to provide comfort and reassurance through routine.