Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a newborn and calculating the Apgar score. At 1 min after delivery, the following findings are noted: heart rate of 110/min; slow, weak cry, some flexion of extremities; grimace in response to suctioning of the nares; body pink in color with blue extremities.
Calculate the newborn's Apgar score.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Custom Nur209 Final Assessment Sp 2024 Proctored Exam. Take the full exam now
Full Explanation
The Apgar score is 6.
It is based on 5 signs evaluated at 1 and 5 minutes after delivery that indicate the physiologic state of the neonate: heart rate over 100 = 2; slow, weak cry = 1; some flexion of extremities = 1; grimace in response to suctioning of the nares = 1; body pink in color with blue extremities = 1.
Total score= 6
Similar Questions
A nurse is preparing to administer acetaminophen 10 mg/kg/dose to a child who weighs 28 lb. The amount available is acetaminophen 120 mg/5 mL. How many mL should the nurse administer?
(Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Full Explanation
To calculate the dosage of acetaminophen for the child, first convert the child's weight from pounds to kilograms, knowing that 1 kilogram equals 2.2 pounds.
The child weighs 28 lb, which is approximately 12.7 kg (28 / 2.2 = 12.7).
The prescribed dose is 10 mg/kg, so the child's dose is 127 mg (10 mg/kg 12.7 kg).
Now, using the concentration of the available medication, which is 120 mg/5 mL, you can calculate the volume of medication needed.
For 120 mg of acetaminophen, 5 mL of liquid is required, so for 127 mg, it would be 5 mL (127 mg / 120 mg) = 5.29 mL.
Therefore, the nurse should administer 5.3 mL, rounding to the nearest tenth as instructed.
A nurse reports an incident of suspected child abuse. One of the parents of the child becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurse is appropriate?
A. "I am unable to discuss this, but I can contact my supervisor to speak with you."
This choice is partially correct because it addresses the parent's concern by offering toinvolve the supervisor. However, it does not provide the parent with the specific reason why the incident was reported.
B. "The provider will be coming to explain the situation."
This response defers the explanation to another time and person, which may increase the parent's frustration or anxiety.
C. "I reported the incident to my supervisor who decided to contact the authorities."
This choice explains the action taken but does not clarify the nurse's legal obligation to report the incident, which is the central issue.
D. "As a nurse, I am required by law to report suspected child abuse."
This is the most appropriate response as it clearly communicates the nurse's legal responsibility to report any suspected cases of child abuse, providing transparency and understanding of the actions taken.
Full Explanation
A. This choice is partially correct because it addresses the parent's concern by offering to
involve the supervisor. However, it does not provide the parent with the specific reason why the incident was reported.
B. This response defers the explanation to another time and person, which may increase the parent's frustration or anxiety.
C. This choice explains the action taken but does not clarify the nurse's legal obligation to report the incident, which is the central issue.
D. This is the most appropriate response as it clearly communicates the nurse's legal responsibility to report any suspected cases of child abuse, providing transparency and understanding of the actions taken.
A nurse is providing care at a routine visit for a client who is at 36 weeks of gestation.
Nurses' Notes
0900:
Reports to clinic for routine visit. Reports a mild headache for the last several days as well as "heartburn." Denies visual disturbances. Also denies vaginal bleeding or leakage of fluid from the vagina. Reports Occasional contraction and positive fetal movement. Also reports they are unable to remove rings from fingers for the last several days.
1000:
Reports headache is more severe and rates pain as a 5 on a 0 to 10 pain scale. Reports feeling dizzy when they got up from examination table.
Vital Signs
0900:
- Temperature:36.9° C (98.4° F)
- Heart rate 100/min
- Respiratory rate 22/min
- Blood pressure 156/90 mm Hg
1000:
- Temperature 36.8° C (98.2° F)
- Heart rate 100/min
- Respiratory rate:21/min
- Blood pressure 160/96 mm Hg
Physical Examination
0900:
Lungs clear to auscultation in all lobes, anterior, posterior, and lateral. Abdomen gravid and soft to palpation. Fundal height 37 cm. Facial edema observed as well as +3 edema in the lower extremities. Patellar reflex 3+, clonus negative. Fetal heart rate 158/min.
Which of the following findings should the nurse report to the provider? (Select all that apply.)
A. Deep tendon reflexes
Deep tendon reflexes are not mentioned in the notes, and there are no indications that they are abnormal or concerning based on the information provided.
B. Respiratory rate
The respiratory rate is within normal limits and is not significantly abnormal. There are no indications in the notes to suggest respiratory distress or other respiratory issues.
C. Cerebral manifestations
The client's symptoms of a severe headache, dizziness upon standing, and inability to remove rings, along with the elevated blood pressure, suggest potential cerebralmanifestations such as preeclampsia. These symptoms warrant further evaluation and intervention by the provider.
D. Fetal heart rate
Fetal heart rate is within normal limits and does not indicate any immediate concerns based on the information provided.
E. Blood pressure
The elevated blood pressure (160/96 mm Hg) is a significant finding and may indicate hypertension or preeclampsia, which requires immediate attention from the provider.
F. Gastrointestinal assessment findings
Gastrointestinal assessment findings are not mentioned in the notes, and there are no indications of gastrointestinal issues that would warrant reporting to the provider at this time.
Full Explanation
A. Deep tendon reflexes are not mentioned in the notes, and there are no indications that they are abnormal or concerning based on the information provided.
B. The respiratory rate is within normal limits and is not significantly abnormal. There are no indications in the notes to suggest respiratory distress or other respiratory issues.
C. The client's symptoms of a severe headache, dizziness upon standing, and inability to remove rings, along with the elevated blood pressure, suggest potential cerebral
manifestations such as preeclampsia. These symptoms warrant further evaluation and intervention by the provider.
D. Fetal heart rate is within normal limits and does not indicate any immediate concerns based on the information provided.
E. The elevated blood pressure (160/96 mm Hg) is a significant finding and may indicate hypertension or preeclampsia, which requires immediate attention from the provider.
F. Gastrointestinal assessment findings are not mentioned in the notes, and there are no
indications of gastrointestinal issues that would warrant reporting to the provider at this time.