A nurse is present during the delivery of a healthy term newborn. The baby is delivered vaginally and does not require any resuscitation efforts. One minute after birth, the nurse assesses the newborn using the Apgar score. The nurse finds the following: Makes a strong cry, Pulse (heart rate): 120 beats per minute (bpm), Pink all over, Active movement, Deep, regular breaths.

What is the MOST likely Apgar score for this newborn?

Answer and Explanation

The Correct Answer is D

Based on the Apgar score components provided, the newborn would likely receive the following scores:

Appearance (color): Pink all over - 2 points
Pulse (heart rate): 120 bpm - 2 points
Grimace (reflex irritability): Makes a strong cry - 2 points
Activity (muscle tone): Active movement - 2 points
Respiration: Deep, regular breaths - 2 points

Adding these together, the newborn’s Apgar score would be 10, which indicates the baby is in excellent condition following delivery.

The Apgar score is a quick assessment method used to evaluate a newborn baby’s health immediately after birth and again 5 minutes later. It was created by Dr. Virginia Apgar in 1952 and is an important tool for healthcare professionals to determine the immediate physical condition of a newborn and the need for any urgent medical care.

Here’s what the Apgar score measures, with each category receiving a score from 0 to 2:

Appearance (color): Checks the baby’s skin tone
Pulse (heart rate): Measures the heart rate
Grimace (reflex irritability): Assesses the reflex response
Activity (muscle tone): Evaluates muscle tone and movement
Respiration: Observes the breathing effort and regularity

The significance of the Apgar score lies in its ability to provide a standardized and rapid assessment of a newborn’s vital signs and immediate health. It helps to quickly identify babies who are struggling and may need additional medical attention. However, it’s important to note that the Apgar score is not designed to predict long-term health outcomes or neurological development. It’s one of many assessments used to understand a baby’s condition at birth.

Here’s a table that outlines the Apgar score criteria and the points assigned for each:

Table

Criteria	0 Points	1 Point	2 Points
Appearance (Color)	Blue or pale all over	Body pink, extremities blue	Pink all over
Pulse (Heart Rate)	Absent	Less than 100 bpm	100 bpm or more
Grimace Response	No response to stimulation	Grimace or weak cry	Strong cry, pulls away
Activity (Muscle Tone)	Limp	Some flexion of extremities	Active motion
Respiration	Absent	Slow or irregular breathing	Good, strong cry

The Apgar score is calculated at 1 minute and 5 minutes after birth. Each of the five criteria is scored between 0 and 2, with a maximum total score of 10. This scoring system helps medical professionals quickly assess the newborn’s general condition and determine if any immediate medical intervention is needed. A score of 7 to 10 is considered normal, 4 to 6 fairly low, and 3 and below critically low.

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Correct Answer is A

Explanation

The nurse should follow the sequence of 1, 2, 3, 4, 5 when assessing the client’s conjunctiva.This is because the nurse should first apply examination gloves to prevent contamination and infection.Then, the nurse should instruct the client to look up to expose the lower eyelid and conjunctiva.Next, the nurse should place the thumbs below each of the client’s lower eyelids and gently pull the skin down to the top edge of the bony orbital rim.This allows the nurse to inspect the color and condition of the conjunctiva and sclera, noting any color change, swelling, drainage, or lesions.The sclera should be white and the conjunctiva should be pink.

Choice B is wrong because the nurse should not pull down the skin before instructing the client to look up.

This could cause discomfort and injury to the eye.

Choice C is wrong because the nurse should not instruct the client to look up after pulling down the skin.

This could also cause discomfort and injury to the eye.

Choice D is wrong because the nurse should not place the thumbs below each of the client’s lower eyelids before applying examination gloves.

This could introduce infection and irritants to the eye.

A. Place the newborn on the mother’s chest after delivery. B. Wrap the newborn in a blanket and hand to the father. C. Place the newborn in an isolette next to the mother’s bed. D. Dress the newborn in a gown and hat before giving to the mother.

Correct Answer is A

Explanation

Place the newborn on the mother’s chest after delivery.This is because skin-to-skin contact between mother and baby promotes bonding and attachment, which are essential for the baby’s emotional and psychological development.Skin-to-skin contact also helps regulate the baby’s body temperature, heart rate, breathing and blood sugar levels.

Choice B is wrong because wrapping the newborn in a blanket reduces the skin-to-skin contact and may interfere with the bonding process.The father can also bond with the baby by holding him or her against his own skin.

Choice C is wrong because placing the newborn in an isolette separates the baby from the mother and prevents close interaction and communication.The baby may feel insecure and isolated in an isolette.

Choice D is wrong because dressing the newborn in a gown and hat also reduces the skin-to-skin contact and may delay the initiation of breastfeeding.The baby may also lose more heat through clothing than through direct contact with the mother’s body.

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Explanation

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