At one minute after birth, an infant is crying, has a heart rate of 140, has acrocyanosis, resists the suction catheter, and keeps his arms extended and his legs flexed. What is the Apgar score?

Correct Answer: C

Rationale: The Apgar score is based on five components: heart rate, respiratory effort, muscle tone, reflex irritability, and color. In this case, the infant has a heart rate over 100 (2 points), is crying (2 points indicating good respiratory effort), resists the catheter (2 points for good reflex irritability), but has acrocyanosis (partial point deduction of 1). Thus, the Apgar score at one minute after birth would be 8. Choice A is incorrect as the given signs indicate a higher score. Choice B is incorrect as the signs described support a score above 6. Choice D is incorrect as it represents a perfect score which is not the case here due to acrocyanosis.

Correct Answer: C

Rationale: The nurse should ensure that the weights in traction are not touching the foot of the bed. This is crucial to maintain proper alignment and effectiveness of the traction. When the weights touch the bed, it can compromise the traction's function and delay healing. Choices A, B, and D are incorrect as they do not address the issue of ensuring that the weights are not touching the bed, which is essential for the traction to work effectively.

Correct Answer: C

Rationale: A dark purple stoma may indicate compromised blood flow to the stoma, which is an emergency. Immediate notification of the healthcare provider is necessary to prevent further complications. Simply documenting and monitoring the finding (Choice A) could lead to delays in addressing a potentially serious issue. Applying warm compresses to the stoma (Choice B) may not address the underlying cause of the dark purple color. Encouraging the client to ambulate (Choice D) is not the priority when a compromised blood flow to the stoma is suspected.

Correct Answer: A

Rationale: Assessing bowel sounds is crucial in this situation as it helps determine if the client's gastrointestinal tract is functioning properly. Absent or hypoactive bowel sounds can indicate an ileus, a common post-operative complication. Assessing fluid intake (Choice B) is important but should come after assessing bowel sounds. Pain assessment (Choice C) is essential but addressing the physiological issue should take precedence. Checking the surgical incision (Choice D) is relevant but not the priority when the client is experiencing abdominal distention and potential gastrointestinal complications.

Correct Answer: B

Rationale: The correct answer is Fragile X syndrome because it is the most common inherited cause of intellectual disability, resulting from a mutation in the FMR1 gene. Down syndrome, Prader-Willi syndrome, and Turner syndrome are not the most common genetic causes of intellectual disability. Down syndrome is caused by the presence of an extra chromosome 21, Prader-Willi syndrome results from specific genetic abnormalities on chromosome 15, and Turner syndrome is characterized by the absence of part or all of one of the X chromosomes.

Correct Answer: C

Rationale: A palpable buzzing sensation, known as a thrill, over an AV fistula indicates proper functioning. The correct action for the PN is to document that the fistula is intact. Choice A is incorrect because there is no need to loosen the fistula dressing when the thrill is felt. Choice B is incorrect as a bounding pulse is not related to the observed buzzing sensation. Choice D is incorrect because applying pressure is unnecessary when a thrill is present, indicating proper AV fistula function.

Correct Answer: D

Rationale: The correct answer is D: Using the deltoid muscle for administration. Administering parenteral iron in the deltoid muscle is not recommended due to the risk of irritation and pain. The Z-track method (choice A) is preferred to prevent staining and irritation of the skin when administering irritating medications like iron. Using an air bubble (choice B) to avoid withdrawing medication into subcutaneous tissue is a common practice to ensure accurate administration. Not massaging the injection site (choice C) is also a standard practice to prevent potential irritation or bleeding at the injection site.

Correct Answer: A

Rationale: Continuous bubbling in the water seal chamber of a chest tube system indicates an air leak. An air leak can prevent the lung from fully re-expanding and may lead to complications like a recurrent pneumothorax. Therefore, it is crucial to investigate and address the air leak promptly. Choices B and C are incorrect because continuous bubbling is not normal and does not indicate lung expansion. Choice D is incorrect because the nurse should first assess and then report the issue to the healthcare provider.

Correct Answer: C

Rationale: Thrombosis is a condition involving blood clots and is not related to posture or body alignment, unlike kyphosis, scoliosis, and lumbar lordosis, which are spinal alignment issues. Kyphosis refers to excessive outward curvature of the spine, scoliosis is characterized by a sideways curvature of the spine, and lumbar lordosis involves an exaggerated inward curve in the lower back. Thrombosis, on the other hand, is a condition where blood clots form in the blood vessels, not a posture or body alignment problem.