The nurse accepts the newborn in the delivery room and performs ...

[Jramos095]

The nurse accepts the newborn in the delivery room and performs an Apgar assessment at one minute of life. The infant is crying vigorously, has a heart rate of 160, is actively moving all extremities, and has blue hands and feet.
 
  The nurse scores the infant as an Apgar of: 1. 6.
  2. 7.
  3. 8.
  4. 9.

Question 2

When assessing a client diagnosed with left-sided heart failure, the nurse anticipates which of the following findings?
 
  1. Abdominal distention
  2. Liver enlargement
  3. Edema of the feet and ankles
  4. Shortness of breath

[ErinKing]

Answer to Question 1

4
Rationale: The infant is scored 2 for heart rate above 100, 2 for respiratory rate, 2 for muscle tone, 2 for vigorous cry, and 1 for color, totaling 9.

Answer to Question 2

4
Rationale: Left-sided failure results in backflow of blood from the pulmonary system, resulting in pulmonary edema and shortness of breath. Edema of the feet and ankles, and liver enlargement, would be seen in clients with right-sided failure due to backup of blood return from the body. Abdominal distention is not usually a symptom of heart failure.