What is nurse's primary critical observation when performing an assessment for determining an Apgar score?

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Question 1 of 5

What is nurse's primary critical observation when performing an assessment for determining an Apgar score?

Correct Answer: A

Rationale: Apgar score assesses newborn vitality at 1 and 5 minutes post-birth across five criteria: heart rate, respiration, muscle tone, reflex, color. Heart rate (choice A) is primary; absent (<60 bpm = 0, <100 = 1, >100 = 2) dictates immediate resuscitation, making it the most critical. Respiratory rate (choice B) follows, but weak/absent breathing often ties to heart rate. Meconium (choice C) isn't scored directly, though it flags distress. Moro reflex (choice D) tests tone/reflex, secondary to vitals. A is correct, as heart rate drives initial intervention. Nurses prioritize it, ensuring rapid response to stabilize the infant.

Question 2 of 5

The coronary vessels, unlike any other blood vessels in the body, respond to sympathetic stimulation by

Correct Answer: B

Rationale: The coronary vessels are unique because they respond to sympathetic stimulation with vasodilatation, unlike most other blood vessels which constrict. Sympathetic stimulation activates the fight-or-flight response, increasing heart rate and oxygen demand. To meet this demand, the coronary arteries dilate to supply more blood to the heart muscle. Vasoconstriction (A) is incorrect as it would reduce blood flow, countering the heart's needs during stress. Decreases in force of contractility (C) or cardiac output (D) are unrelated to the vascular response and pertain more to myocardial function, not the coronary vessels' behavior. This vasodilatation is mediated by beta-adrenergic receptors, ensuring adequate perfusion during heightened activity, making B the correct choice.

Question 3 of 5

What stress response can you expect from a patient with blood sugar of 50 mg/dl?

Correct Answer: C

Rationale: A blood sugar level of 50 mg/dl indicates hypoglycemia, a stress state triggering the body's fight-or-flight response. The client will appear restless due to the brain's reliance on glucose; low levels cause agitation as a protective mechanism to signal distress. The body attempts to increase glucose via glycogenolysis and gluconeogenesis (opposite of A), so decreasing glucose further is incorrect. Halting sex hormone release (B) occurs in chronic stress, not acute hypoglycemia. Blood pressure may rise (D) due to catecholamine release, but restlessness is the most immediate and observable response in this acute scenario, aligning with early stress symptoms. Thus, C is correct as it directly reflects the patient's presentation during a hypoglycemic crisis.

Question 4 of 5

Nurse Aida has seen her patient, Roger for the first time. She establish a contract about the frequency of meeting and introduce to Roger the expected termination. She started taking baseline assessment and set interventions and outcomes. On what phase of NPR Does Nurse Aida and Roger belong?

Correct Answer: B

Rationale: Nurse Aida and Roger are in the Orientation phase (B). This stage involves the first meeting, establishing a contract (meeting frequency, termination expectations), and initial assessments to set goals. Pre-Orientation (A) is before contact, reviewing records. Working (C) focuses on implementing plans, and Termination (D) ends the relationship. Orientation, per Peplau, sets the foundation with trust and planning, matching Aida's actions, making B correct.

Question 5 of 5

Roger has been seen agitated, shouting and running. As Nurse Aida approaches, he shouts and swear, calling Aida names. Nurse Aida told Roger 'That is an unacceptable behavior Roger, Stop and go to your room now.' The situation is most likely in what phase of NPR?

Correct Answer: C

Rationale: This scenario fits the Working phase (C). Roger's agitation and Aida's response setting boundaries suggest an established relationship where interventions address behaviors. Pre-Orientation (A) is pre-contact, Orientation (B) builds trust, not confrontation, and Termination (D) ends care. In Peplau's Working phase, the nurse actively helps the client manage issues, as Aida does here, making C the likely phase.

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