Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
What Apgar score should a nurse document for a newborn with a pink trunk and head, bluish hands and feet, flexed extremities 5 min after delivery, a weak and slow cry, a heart rate of 130/min, and cries in response to suctioning?
A. 7
An Apgar score of 7 is considered fairly low and would typically be associated with a newborn who has more significant health concerns.
B. 8
An Apgar score of 8 is considered to be within the normal range. This score would be consistent with a newborn who has a pink trunk and head, bluish hands and feet, flexed extremities, a weak and slow cry, a heart rate of 130/min, and cries in response to suctioning.
C. 9
An Apgar score of 9 is considered to be within the normal range. However, given the newborn’s weak and slow cry, an Apgar score of 9 would be less likely.
D. 10
An Apgar score of 10 is very unusual, as almost all newborns lose 1 point for blue hands and feet, which is normal for after birth.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Nur 232 Maternity Final Proctored Exam Sp24. Take the full exam now
Full Explanation
Choice A rationale
An Apgar score of 7 is considered fairly low and would typically be associated with a newborn who has more significant health concerns.
Choice B rationale
An Apgar score of 8 is considered to be within the normal range. This score would be consistent with a newborn who has a pink trunk and head, bluish hands and feet, flexed extremities, a weak and slow cry, a heart rate of 130/min, and cries in response to suctioning.
Choice C rationale
An Apgar score of 9 is considered to be within the normal range. However, given the newborn’s weak and slow cry, an Apgar score of 9 would be less likely.
Choice D rationale
An Apgar score of 10 is very unusual, as almost all newborns lose 1 point for blue hands and feet, which is normal for after birth.
Similar Questions
What is the estimated date of birth (EDB) for a client who is pregnant and whose last menstrual period began on July 27? (State the date in MMDD.
For example, July 27 is 0727)
A. 0427
To calculate the estimated date of birth (EDB) using the first day of the last menstrual period (LMP), you can use Naegele’s Rule. This rule adds 280 days (or 40 weeks) to the first day of the LMP. Given the LMP of July 27 (0727): Add 1 year: July 27, 2023 becomes July 27, 2024. Add 7 days: July 27, 2024 becomes August 3, 2024. Subtract 3 months: August 3, 2024 becomes May 3, 2024. So, the estimated date of birth (EDB) is May 3, 2024 (0503).
B. 0503
To calculate the estimated date of birth (EDB) using the first day of the last menstrual period (LMP), you can use Naegele’s Rule. This rule adds 280 days (or 40 weeks) to the first day of the LMP. Given the LMP of July 27 (0727): Add 1 year: July 27, 2023 becomes July 27, 2024. Add 7 days: July 27, 2024 becomes August 3, 2024. Subtract 3 months: August 3, 2024 becomes May 3, 2024. So, the estimated date of birth (EDB) is May 3, 2024 (0503).
C. 0603
To calculate the estimated date of birth (EDB) using the first day of the last menstrual period (LMP), you can use Naegele’s Rule. This rule adds 280 days (or 40 weeks) to the first day of the LMP. Given the LMP of July 27 (0727): Add 1 year: July 27, 2023 becomes July 27, 2024. Add 7 days: July 27, 2024 becomes August 3, 2024. Subtract 3 months: August 3, 2024 becomes May 3, 2024. So, the estimated date of birth (EDB) is May 3, 2024 (0503).
D. 0527
To calculate the estimated date of birth (EDB) using the first day of the last menstrual period (LMP), you can use Naegele’s Rule. This rule adds 280 days (or 40 weeks) to the first day of the LMP. Given the LMP of July 27 (0727): Add 1 year: July 27, 2023 becomes July 27, 2024. Add 7 days: July 27, 2024 becomes August 3, 2024. Subtract 3 months: August 3, 2024 becomes May 3, 2024. So, the estimated date of birth (EDB) is May 3, 2024 (0503).
Full Explanation
To calculate the estimated date of birth (EDB) using the first day of the last menstrual period (LMP), you can use Naegele’s Rule. This rule adds 280 days (or 40 weeks) to the first day of the LMP.
Given the LMP of July 27 (0727):
- Add 1 year: July 27, 2023 becomes July 27, 2024.
- Add 7 days: July 27, 2024 becomes August 3, 2024.
- Subtract 3 months: August 3, 2024 becomes May 3, 2024.
So, the estimated date of birth (EDB) is May 3, 2024 (0503).
Which of the following findings should alert a nurse assessing a client who is 8 hr postpartum and multiparous?
A. Fundus three fingerbreadths above the umbilicus.
A fundus that is three fingerbreadths above the umbilicus 8 hours postpartum is a sign of urinary retention, which can displace the uterus and inhibit uterine contraction, leading to postpartum hemorrhage.
B. Moderate lochia rubra.
Moderate lochia rubra, or bloody discharge, is normal within the first few days after childbirth.
C. Blood pressure 130/84 mm Hg.
A blood pressure of 130/84 mm Hg is within the normal range for a postpartum woman.
D. Moderate swelling of the labia.
Moderate swelling of the labia can be a normal finding after a vaginal birth.
Full Explanation
Choice A rationale
A fundus that is three fingerbreadths above the umbilicus 8 hours postpartum is a sign of urinary retention, which can displace the uterus and inhibit uterine contraction, leading to postpartum hemorrhage.
Choice B rationale
Moderate lochia rubra, or bloody discharge, is normal within the first few days after childbirth.
Choice C rationale
A blood pressure of 130/84 mm Hg is within the normal range for a postpartum woman.
Choice D rationale
Moderate swelling of the labia can be a normal finding after a vaginal birth.
What is the most likely cause of respiratory distress syndrome in a term macrosomic newborn whose mother has poorly controlled type 2 diabetes?
A. Increased deposits of fat in the chest and shoulder area.
Increased deposits of fat in the chest and shoulder area are not typically associated with respiratory distress syndrome in a term macrosomic newborn whose mother has poorly controlled type 2 diabetes.
B. Hyperinsulinemia.
Hyperinsulinemia is a condition in which there are excess levels of insulin circulating in the blood. In the case of a term macrosomic newborn whose mother has poorly controlled type 2 diabetes, the baby’s pancreas may produce extra insulin in response to the mother’s high blood glucose levels. This excess insulin can delay surfactant production, which is needed for lung maturation, leading to respiratory distress syndrome.
C. Brachial plexus injury.
Brachial plexus injury is a type of birth injury that can occur due to the baby’s large size and difficulty being born. However, it is not the most likely cause of respiratory distress syndrome in a term macrosomic newborn whose mother has poorly controlled type 2 diabetes.
D. Increased blood viscosity.
Increased blood viscosity can occur in newborns of mothers with poorly controlled diabetes due to polycythemia (an abnormally high number of red blood cells). However, this is not the most likely cause of respiratory distress syndrome in a term macrosomic newborn.
Full Explanation
Choice A rationale
Increased deposits of fat in the chest and shoulder area are not typically associated with respiratory distress syndrome in a term macrosomic newborn whose mother has poorly controlled type 2 diabetes.
Choice B rationale
Hyperinsulinemia is a condition in which there are excess levels of insulin circulating in the blood. In the case of a term macrosomic newborn whose mother has poorly controlled type 2 diabetes, the baby’s pancreas may produce extra insulin in response to the mother’s high blood glucose levels. This excess insulin can delay surfactant production, which is needed for lung maturation, leading to respiratory distress syndrome.
Choice C rationale
Brachial plexus injury is a type of birth injury that can occur due to the baby’s large size and difficulty being born. However, it is not the most likely cause of respiratory distress syndrome in a term macrosomic newborn whose mother has poorly controlled type 2 diabetes.
Choice D rationale
Increased blood viscosity can occur in newborns of mothers with poorly controlled diabetes due to polycythemia (an abnormally high number of red blood cells). However, this is not the most likely cause of respiratory distress syndrome in a term macrosomic newborn.