Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A. Heart rate, respiratory effort.
Heart rate and respiratory effort are two of the five parameters of the Apgar score. However, this choice is incomplete as it does not include all five parameters.
B. Temperature, tone.
Temperature is not a parameter of the Apgar score. Tone is a parameter, but this choice is incomplete as it does not include all five parameters.
C. And color.
Color is a parameter of the Apgar score. However, this choice is incomplete as it does not include all five parameters.
D. Heart rate, breaths per minute, irritability, tone, and color.
The Apgar score is based on five parameters: heart rate, breaths per minute (respiratory effort), irritability (response to stimulation), tone (muscle tone), and color. Therefore, this choice is correct.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN Custom 2023 Fall NPRO 1100 Proctored Exam 3. Take the full exam now
Full Explanation
The correct answer is choice D.
Choice A rationale:
Heart rate and respiratory effort are two of the five parameters of the Apgar score. However, this choice is incomplete as it does not include all five parameters.
Choice B rationale:
Temperature is not a parameter of the Apgar score. Tone is a parameter, but this choice is incomplete as it does not include all five parameters.
Choice C rationale:
Color is a parameter of the Apgar score. However, this choice is incomplete as it does not include all five parameters.
Choice D rationale:
The Apgar score is based on five parameters: heart rate, breaths per minute (respiratory effort), irritability (response to stimulation), tone (muscle tone), and color. Therefore, this choice is correct.
Similar Questions
A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad.
The fundus is midline and firm at the umbilicus.
Which of the following actions should the nurse take?.
A. Notify the client's provider.
Notifying the provider is not necessary in this case as the findings are normal for a client who is 1 hour postpartum.
B. Increase the frequency of fundal massage.
Increasing the frequency of fundal massage is not necessary as the fundus is firm and at the umbilicus.
C. Document the findings and continue to monitor the client.
The findings are normal for a client who is 1 hour postpartum. The nurse should document the findings and continue to monitor the client. Therefore, this choice is correct.
D. Encourage the client to empty her bladder.
Encouraging the client to empty her bladder is not necessary in this case as the fundus is midline.
Full Explanation
The correct answer is choice C.
Choice A rationale:
Notifying the provider is not necessary in this case as the findings are normal for a client who is 1 hour postpartum.
Choice B rationale:
Increasing the frequency of fundal massage is not necessary as the fundus is firm and at the umbilicus.
Choice C rationale:
The findings are normal for a client who is 1 hour postpartum. The nurse should document the findings and continue to monitor the client. Therefore, this choice is correct.
Choice D rationale:
Encouraging the client to empty her bladder is not necessary in this case as the fundus is midline.
A nurse is caring for a client who is postpartum and has a prescription for Rho (D) immunoglobulin.
The nurse should verify which of the following prior to administration?.
A. Client is Rh negative and the newborn is Rh negative.
Rho (D) immunoglobulin is not administered when both the client and the newborn are Rh negative.
B. Client is Rh positive and the newborn is Rh positive.
Rho (D) immunoglobulin is not administered when both the client and the newborn are Rh positive.
C. Client is Rh positive and the newborn is Rh negative.
Rho (D) immunoglobulin is not administered when the client is Rh positive and the newborn is Rh negative.
D. Client is Rh negative and the newborn is Rh positive.
Rho (D) immunoglobulin is administered when the client is Rh negative and the newborn is Rh positive. Therefore, this choice is correct.
Full Explanation
The correct answer is choice D.
Choice A rationale:
Rho (D) immunoglobulin is not administered when both the client and the newborn are Rh negative.
Choice B rationale:
Rho (D) immunoglobulin is not administered when both the client and the newborn are Rh positive.
Choice C rationale:
Rho (D) immunoglobulin is not administered when the client is Rh positive and the newborn is Rh negative.
Choice D rationale:
Rho (D) immunoglobulin is administered when the client is Rh negative and the newborn is Rh positive. Therefore, this choice is correct.
A nurse is providing teaching about comfort measures for breast engorgement to a client who is postpartum and is breastfeeding.
Which of the following statements by the client indicates a need for further teaching?.
A. "I should crush cabbage leaves and place them on my breasts.”. .
Cabbage leaves have been used for many years for relief of breast engorgement. They can be crushed slightly until the juice is visible and then chilled in the refrigerator before applying to the breasts.
B. "I should apply hot packs to my breasts during feeding.”. .
Applying hot packs during feeding can actually increase blood flow and make engorgement worse. Cold packs should be used after feeding to help reduce swelling.
C. "I will apply ice packs to my breasts after feeding.”. .
Applying ice packs after feeding can help reduce swelling and provide relief from engorgement.
D. "I will breastfeed every 2 hours.”.
Frequent breastfeeding can help to relieve engorgement. The breasts should be emptied completely at each feeding.
Full Explanation
The correct answer is choice B.
Choice A rationale:
Cabbage leaves have been used for many years for relief of breast engorgement. They can be crushed slightly until the juice is visible and then chilled in the refrigerator before applying to the breasts.
Choice B rationale:
Applying hot packs during feeding can actually increase blood flow and make engorgement worse. Cold packs should be used after feeding to help reduce swelling.
Choice C rationale:
Applying ice packs after feeding can help reduce swelling and provide relief from engorgement.
Choice D rationale:
Frequent breastfeeding can help to relieve engorgement. The breasts should be emptied completely at each feeding.