Provide the 1-minute Apgar score for an infant born with the following findings: Heart rate: Above
100 Respiratory effort: Slow, irregular Muscle tone: Some flexion of extremities Reflex irritability:
Vigorous cry Color: Body pink, blue extremities
A
Explanation:
(A) Seven out of a possible perfect score of 10 is correct. Two points are given for heart rate above
100; 1 point is given for slow, irregular respiratory effort; 1 point is given for some flex- ion of
extremities in assessing muscle tone; 2 points are given for vigorous cry in assessing reflex irritability;
1 point is assessed for color when the body is pink with blue extremities (acrocyanosis). (B) For a
perfect Apgar score of 10, the infant would have a heart rate over 100 but would also have a good
cry, active motion, and be completely pink. (C) For an Apgar score of 8 the respiratory rate, muscle
tone, or color would need to fall into the 2-point rather than the 1-point category. (D) For this infant
to receive an Apgar score of 9, four of the areas evaluated would need ratings of 2 points and one
area, a rating of 1 point.
A pregnant woman at 36 weeks’ gestation is followed for PIH and develops proteinuri
a. To increase protein in her diet, which of the following foods will provide the greatest amount of
protein when added to her intake of 100 mL of milk?
B
Explanation:
(A) This choice would provide more unwanted fat and sugar than protein. (B) Skim milk would add
protein. Eggs are good sources of protein while low in fat and calories. (C) The benefit of protein
from ice cream would be outweighed by the fat content. Chocolate syrup has caffeine, which is
contraindicated or limited in pregnancy. (D) Although most animal proteins are higher in protein than
plant proteins, gelatin is not. It loses protein during the processing for food consumption.
The physician recommends immediate hospital admission for a client with PIH. She says to the nurse,
“It’s not so easy for me to just go right to the hospital like that.” After acknowledging her feelings,
which of these approaches by the nurse would probably be best?
B
Explanation:
(A) This answer does not hold the client accountable for her own health. (B) The nurse should explore
potential reasons for the client’s anxiety: are there small children at home, is the husband out of
town? The nurse should aid the client in seeking support or interventions to decrease the anxiety of
hospitalization. (C) Repeating the physician’s reason for recommending hospitalization may not aid
the client in dealing with her reasons for anxiety. (D) The concern for self and welfare of baby may be
secondary to a woman who is in a crisis situation. The nurse should explore the client’s potential
reasons for anxiety. For example, is there another child in the home who is ill, or is there a husband
who is overseas and not able to return on short notice?
Which of the following findings would be abnormal in a postpartal woman?
D
Explanation:
(A) Frequently the mother experiences a shaking chill immediately after delivery, which is related to
a nervous response or to vasomotor changes. If not followed by a fever, it is clinically innocuous. (B)
The pulse rate during the immediate postpartal period may be low but presents no cause for alarm.
The body attempts to adapt to the decreased pressures intra-abdominally as well as from the
reduction of blood flow to the vascular bed. (C) Urinary output increases during the early postpartal
period (12–24 hours) owing to diuresis. The kidneys must eliminate an estimated 2000–3000 mL of
extracellular fluid associated with a normal pregnancy. (D) A temperature of 100.4F (38C) may occur
after delivery as a result of exertion and dehydration of labor. However, any temperature greater
than 100.4F needs further investigation to identify any infectious process.
What is the most effective method to identify early breast cancer lumps?
D
Explanation:
(A) Mammograms are less effective than breast self-examination for the diagnosis of abnormalities
in younger women, who have denser breast tissue. They are more effective forwomen older than 40.
(B) Up to 15% of early-stage breast cancers are detected by physical examination; however, 95% are
detected by women doing breast self-examination. (C) Ultrasound is used primarily to determine the
location of cysts and to distinguish cysts from solid masses. (D) Monthly breast self-examination has
been shown to be the most effective method for early detection of breast cancer. Approximately 95%
of lumps are detected by women themselves.
Which of the following risk factors associated with breast cancer would a nurse consider most
significant in a client’s history?
C
Explanation:
(A) Women who begin menarche late (after 13 years old) have a lower risk of developing breast
cancer than women who have begun earlier. Average age for menarche is 12.5 years. (B) Women
who have never been pregnant have an increased risk for breast cancer, but a positive family history
poses an even greater risk. (C) A positive family history puts a woman at an increased risk of
developing breast cancer. It is recommended that mammography screening begin 5 years before the
age at which an immediate female relative was diagnosed with breast cancer. (D) Early menopause
decreases the risk of developing breast cancer.
Which of the following procedures is necessary to establish a definitive diagnosis of breast cancer?
D
Explanation:
(A) Diaphanography, also known as transillumination, is a painless, noninvasive imaging technique
that involves shining a light source through the breast tissue to visualize the interior. It must be used
in conjunction with a mammogram and physical examination. (B) Mammography is a useful tool for
screening but is not considered a means of diagnosing breast cancers. (C) Thermography is a pictorial
representation of heat patterns on the surface of the breast. Breast cancers appear as a “hot spot”
owing to their higher metabolic rate. (D) Biopsy either by needle aspiration or by surgical incision is
the primary diagnostic technique for confirming the presence of cancer cells.
The nurse should know that according to current thinking, the most important prognostic factor for a
client with breast cancer is:
B
Explanation:
(A) Although tumor size is a factor in classification of cancer growth, it is not an indicator of lymph
node spread. (B) Axillary node status is the most important indicator for predicting how far the
cancer has spread. If the lymph nodes are positive for cancer cells, the prognosis is poorer. (C) The
client’s previous history of cancer puts her at an increased risk for breast cancer recurrence,
especially if the cancer occurred in the other breast. It does not predict prognosis, however. (D) The
estrogen-progesterone assay test is used to identify present tumors being fedfrom an estrogen site
within the body. Some breast cancers grow rapidly as long as there is an estrogen supply such as
from the ovaries. The estrogen-progesterone assay test does not indicate the prognosis.
When teaching a sex education class, the nurse identifies the most common STDs in the United
States as:
A
Explanation:
(A) Chlamydia trachomatis infection is the most common STD in the United States. The Centers for
Disease Control and Prevention recommend screening of all high-risk women, such as adolescents
and women with multiple sex partners. (B) Herpes simplex genitalia is estimated to be found in 5–20
million people in the United States and is rising in occurrence yearly. (C) Syphilis is a chronic infection
caused by Treponema pallidum. Over the last several years the number of people infected has begun
to increase. (D) Gonorrhea is a bacterial infection caused by the organism Neisseria gonorrhoeae.
Although gonorrhea is common, chlamydia is still the most common STD.
A 30-year-old male client is admitted to the psychiatric unit with a diagnosis of bipolar disorder. For
the last 2 months, his family describes him as being “on the move,” sleeping 3–4 hours nightly,
spending lots of money, and losing approximately 10 lb. During the initial assessment with the client,
the nurse would expect him to exhibit which of the following?
C
Explanation:
(A) During the manic phase of bipolar disorder, clients have short attention spans and may be
abusive toward authority figures. (B) Introspection requires focusing and concentration; clients with
mania experience flight of ideas, which prevents concentration.
(C) Grandiosity and an inflated sense of self-worth are characteristic of this disorder. (D) Feelings of
helplessness and hopelessness are symptoms of the depressive stage of bipolar disorder.