At 1 minute after birth, the nurse assesses the infant and notes a heart rate of 80 beats/minute, some flexion of the extremities, a weak cry, grimacing, and a pink body with blue extremities. The nurse would calculate an Apgar score of: ________
What will be an ideal response?
ANS:
5
Each of the five signs the nurse noted would score an Apgar of 1 for a total of 5. Signs include heart rate, respiratory effort, muscle tone, reflex irritability, and color. The highest possible Apgar score is 10.
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A visiting nurse is concerned that a mother has not properly bonded with her infant. The nurse should assess for what factors that could impact this process? (Select all that apply.)
A. Chaotic home life B. Disappointment in her birth experience C. Lack of family support D. Poverty E. Substance abuse
The electrocardiogram of a patient receiving tPA for a myocardial infarction shows that the ST segment has returned to baseline. How should the nurse interpret this finding?
1. The spasm in the coronary artery has resolved. 2. The myocardial injury is evolving. 3. The patient has become more relaxed. 4. The blocked artery has been reperfused.
A child is brought to the emergency department in a coma. The mother thinks the child may have ingested a poison. Which will the nurse assess based on this information? Select all that apply
1. For oral burns 2. The child's breath 3. The child's vomitus 4. Hair samples 5. Blood and urine toxicology screens