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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Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Decreased energy Rationale: Decreased energy is a common symptom during pregnancy due to hormonal changes and increased metabolic demands. While it can be uncomfortable for the client, it is not typically a cause for immediate concern. It is essential to educate the client about the normal changes in energy levels during pregnancy, and that this symptom alone does not warrant calling the provider.
Choice B rationale:
Urinary frequency Rationale: Urinary frequency is a common early pregnancy symptom, primarily attributed to hormonal changes and the growing uterus pressing on the bladder. While it is a normal symptom, it can also be associated with urinary tract infections or other urinary issues. The client should call her provider if she experiences urinary frequency to rule out any potential problems.
Choice C rationale:
Mood swings Rationale: Mood swings are a common occurrence during pregnancy due to hormonal fluctuations. While they can be distressing for the client, they are typically not a sign of an immediate issue that requires contacting the provider. The nurse should educate the client about mood swings being a part of the normal pregnancy experience.
Choice D rationale:
Facial edema Rationale: Facial edema, or swelling of the face, can occur during pregnancy due to fluid retention. However, this symptom is not typically a cause for immediate concern. The nurse should educate the client about normal pregnancy-related changes, including mild edema. Severe facial edema might be a sign of preeclampsia, a condition characterized by high blood pressure and organ damage, but it is generally not a common early sign in pregnancy.
Correct Answer is B
Explanation
Choice A rationale:
Placing the client on seizure precautions is not the appropriate action in this scenario. Shaking chills during the immediate postpartum period are not indicative of a seizure. Seizure precautions involve measures like protecting the client from injury during a seizure, such as moving them to a safe area and providing a padded bed or mattress. This is not relevant to the client's current situation of shaking chills.
Choice C rationale:
Covering the client with warm blankets may provide comfort and help raise body temperature if the client is experiencing chills due to being cold. However, it does not address the underlying cause of the shaking chills. The nurse should first assess the client's temperature to determine the cause of the chills before implementing interventions.
Choice D rationale:
Notifying the charge nurse is not the immediate action needed when a client is experiencing shaking chills. The primary responsibility of the nurse in this situation is to assess and identify the cause of the chills. Once the cause is determined, appropriate interventions can be initiated. It's essential to focus on the immediate assessment of the client's condition.
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