A nurse is assisting in the care of a newborn following birth. At 1 min after birth, the nurse notes the following: heart rate 110/min; slow, weak cry; some flexion of extremities; responds to suctioning of the nares with respiration of 20; body pink in color with blue extremities.
What should the nurse document as the newborn's 1-min Apgar score?
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The Correct Answer is A
A nurse is assisting in the care of a newborn following birth. At 1 min after birth, the nurse notes the following: heart rate 110/min; slow, weak cry; some flexion of extremities; responds to suctioning of the nares with respiration of 20; body pink in color with blue extremities. What should the nurse document as the newborn's 1-min Apgar score? The correct answer is choice B: 7.
Choice A rationale:
Apgar scores are determined by assessing five vital signs in a newborn at 1 and 5 minutes after birth. The vital signs are heart rate, respiratory effort, muscle tone, reflex irritability, and color. Each category is scored from 0 to 2, with 2 being the best score. In this case, the heart rate is 1, the respiratory effort is 1, muscle tone is 1, reflex irritability is 2 (as the newborn responds to suctioning), and color is 2 (as the body is pink). Therefore, the total Apgar score is 7 (1 + 1 + 1 + 2 + 2 = 7).
Choice B rationale:
The heart rate at 1 minute is 110 beats per minute, which is considered normal for a newborn. A slow, weak cry suggests some respiratory effort, which is given a score of 1 on the Apgar scale. Some flexion of extremities also indicates moderate muscle tone and receives a score of 1. Responding to suctioning with respiration indicates good reflex irritability, which is given a score of 2. The body being pink in color is a positive sign for oxygenation and receives a score of 2. Adding up these scores (1 + 1 + 2 + 2) equals 7, which is the 1-minute Apgar score.
Choice C rationale:
Apgar scores are not determined based on gestational age; they focus on the newborn's immediate condition. While gestational age can influence a newborn's health, it is not directly factored into the Apgar score.
Choice D rationale:
The Apgar score is not related to the mother's condition or complications during pregnancy, such as placenta previa. It solely evaluates the newborn's condition at 1 and 5 minutes after birth.
Choice E rationale:
The Apgar score is a quick assessment of the newborn's physical condition and does not consider issues like the mother's gestational diabetes. It focuses on the baby's vital signs and physical appearance to gauge overall well-being.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
As mentioned in the previous question, Rho(D) immune globulin should be administered to Rh-negative pregnant clients when the newborn is Rh positive. This is essential to prevent Rh sensitization and hemolytic disease of the newborn in future pregnancies. So, if the client is Rh negative and the newborn is Rh positive, the nurse should administer Rho(D) immune globulin to prevent complications. Choice A is the correct answer.
Choice B rationale:
If both the client and the newborn are Rh positive, there is no risk of Rh incompatibility, and Rho(D) immune globulin administration is not necessary. Choice B is not the correct answer.
Choice C rationale:
When both the client and the newborn are Rh negative, there is no risk of Rh incompatibility, and therefore, Rho(D) immune globulin administration is not required. Choice C is not the correct answer.
Choice D rationale:
If the client is Rh positive and the newborn is Rh negative, there is no risk of Rh incompatibility, and Rho(D) immune globulin administration is not necessary in this scenario. Choice D is not the correct answer.
Correct Answer is ["C","D","E"]
Explanation
Choice C rationale:
The client's blood pressure of 170/101 mm Hg is significantly elevated. This is a systolic blood pressure above 160 mm Hg and a diastolic blood pressure above 110 mm Hg, which is indicative of severe hypertension. Elevated blood pressure during pregnancy can be a sign of preeclampsia, a condition that can have serious consequences for both the mother and the fetus. Therefore, the nurse should report this finding to the provider immediately. Choice C is the correct answer.
Choice D rationale:
Visual disturbances, such as blurred vision, can be an early symptom of preeclampsia. These symptoms, in combination with the elevated blood pressure, are concerning and should be reported to the provider promptly. Visual disturbances can be a sign of central nervous system involvement in preeclampsia. Choice D is the correct answer.
Choice E rationale:
Blood pressure is a vital sign that should be closely monitored during pregnancy. The elevated blood pressure of 170/101 mm Hg is a critical finding and should be reported to the provider immediately. Elevated blood pressure is one of the key diagnostic criteria for preeclampsia. Choice E is the correct answer.
Choice A rationale:
While changes in respiratory rate can be significant, they are not the primary concern in this scenario. The more pressing issues are the elevated blood pressure and visual disturbances, which are strongly indicative of preeclampsia. Choice A is not the most critical finding in this case.
Choice B rationale:
Fetal heart rate (FHR) of 148 is within the normal range for a fetus. FHR monitoring is important, but in this case, the mother's condition and vital signs take precedence due to the potential risks associated with preeclampsia. Choice B is not the most critical finding in this situation.
Choice F rationale:
Deep tendon reflexes are reported as 3+, which can be a sign of hyperreflexia, a neurological symptom associated with preeclampsia. However, the most immediate concerns in this case are the elevated blood pressure, visual disturbances, and signs of preeclampsia. Choice F is not the most critical finding in this context.
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