Nurse Juvy's assessment reveals the following: Heart Rate is 110 beats per minute, has a vigorous cry, moves actively and with good flexion, normal skin color and bluish extremities. What would be thd APGAR score of Baby Sharon?

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Correct Answer: A

Rationale: The nurse should prioritize using sterile technique during the tracheostomy tube change to ensure patient safety. Tracheostomy procedures involve a direct entry into the airway, making it crucial to prevent infection and reduce the risk of complications. Sterile technique, including proper hand hygiene, wearing sterile gloves, and using sterile equipment, helps minimize the introduction of pathogens into the patient's airway, reducing the risk of infection. By maintaining a sterile field, the nurse can protect the patient from potential harm and promote a successful outcome of the tracheostomy tube change.

Correct Answer: D

Rationale: The patient is presenting with symptoms and laboratory findings consistent with a paraneoplastic syndrome related to Hodgkin lymphoma. In this case, the fever, chills, generalized malaise, pancytopenia, circulating Reed-Sternberg cells, and bone marrow involvement are all indicative of a paraneoplastic syndrome associated with Hodgkin lymphoma. Paraneoplastic syndromes are a group of disorders that are triggered by an abnormal immune response to a neoplasm, such as Hodgkin lymphoma, leading to various systemic manifestations.

Correct Answer: C

Rationale: In this situation, the most appropriate way for the nurse to handle it would be to encourage the mother to keep calm because the health care team is doing their best to help Ramon recover. This response acknowledges the mother's concerns and reassures her that everything possible is being done for her son's well-being. It also helps to foster trust and rapport between the nurse, mother, and the healthcare team, which is important for effective communication and support during a challenging time. Promoting a sense of calm and trust in the healthcare professionals can help alleviate the mother's anxiety and stress, allowing her to focus on being a supportive presence for her son.

Correct Answer: B

Rationale: Obtaining informed consent is primarily the responsibility of the physician. Informed consent is a crucial ethical and legal concept in healthcare that requires the healthcare provider, usually the physician, to ensure that the patient understands the proposed treatment, including the risks, benefits, alternatives, and potential outcomes, before agreeing to proceed with the treatment. While other healthcare professionals, such as nurses, nurse managers, anesthesiologists, and midwives, may also play a role in the informed consent process by providing information and clarifying details, it is ultimately the physician who must obtain the patient's informed consent before any treatment or procedure is performed.

Correct Answer: A

Rationale: This scenario falls under the category of invasion of privacy. Invasion of privacy occurs when a person's private information or images are shared or used without their consent, leading to an intrusion of their private life. In this case, Kris, as a hospitalized movie star, had her picture taken without permission by the nursing assistant, which was later sold to a local newspaper. Kris has a right to privacy, especially during a vulnerable time like being hospitalized, and the nursing assistant violated that right by taking and selling her picture without consent. This action constitutes an invasion of privacy.

Correct Answer: B

Rationale: Oxytocin release is responsible for the mild cramping and uterine contractions experienced by the new mother while breastfeeding. When a baby suckles at the breast, it stimulates nerve endings that signal the release of oxytocin from the posterior pituitary gland. Oxytocin is a hormone that plays a crucial role in stimulating the contraction of the uterine muscles, helping the uterus to contract back to its pre-pregnancy size. This process, known as uterine involution, is essential for postpartum recovery and preventing excessive bleeding. Therefore, the new mother's experience of mild cramping and uterine contractions while breastfeeding is a normal physiological response mediated by the release of oxytocin.

Correct Answer: C

Rationale: Globulin is the blood protein involved in the immune system. There are different types of globulins, including immunoglobulins (antibodies) that play a crucial role in the body's defense against infections. These antibodies bind to foreign substances, such as bacteria and viruses, helping the immune system to recognize and destroy them. Thrombin is a clotting protein, albumin is a protein responsible for maintaining osmotic balance in the blood, and hemoglobin is a protein found in red blood cells that carries oxygen.

Correct Answer: D

Rationale: Sudden chest pain, dyspnea, and tachycardia in a postpartum client can be indicative of serious conditions such as pulmonary embolism or myocardial infarction. These conditions are emergencies that require immediate medical attention. Notifying the healthcare provider immediately is the priority to ensure prompt evaluation and intervention to address the potential life-threatening situation. While other nursing interventions such as elevating the head of the bed, providing supplemental oxygen therapy, and administering analgesics may be necessary, they should be done after notifying the healthcare provider to ensure appropriate management of the underlying cause.