A 25-year-old primigravida client is in the first stage of labor. ...

[moongchi]

A 25-year-old primigravida client is in the first stage of labor. She and her husband have been holding hands and breathing together through each contraction. Suddenly, the client pushes her husband's hand away and shouts,
 
  Don't touch me This behavior is most likely:
 
  a. abnormal labor.
  b. a sign that she needs analgesia.
  c. normal and related to hyperventilation.
  d. common during the transition phase of labor.

Question 2

At 1 minute after birth, the nurse assesses the newborn to assign an Apgar score. The apical heart rate is 110 bpm, and the infant is crying vigorously with the limbs flexed. The infant's trunk is pink, but the hands and feet are blue.
 
  The Apgar score for this infant is:
 
  a. 7.
  b. 8.
  c. 9.
  d. 10.

[strudel15]

Answer to Question 1

ANS: D
The transition phase of labor is often associated with an abrupt change in behavior, including increased anxiety and irritability. This change of behavior is an expected occurrence during the transition phase. If she is in the transitional phase of labor, analgesia may not be appropriate if the birth is near. Hyperventilation will produce signs of respiratory alkalosis.

Answer to Question 2

ANS: C
The Apgar score is 9 because 1 point is deducted from the total score of 10 for the infant's blue hands and feet. The baby received 2 points for each of the categories except color. Because the infant's hands and feet were blue, this category is given a grade of 1. The baby received 2 points for each of the categories except color. Because the infant's hands and feet were blue, this category is given a grade of 1. The infant had 1 point deducted because of the blue color of the hands and feet.