A nurse is caring for a newborn and calculating the Apgar score. At 1 min after delivery, the following findings are noted: heart rate of 110/min; slow, weak cry, some flexion of extremities; grimace in response to suctioning of the nares; body pink in color with blue extremities.
Calculate the newborn's Apgar score.
The Correct Answer is ["6"]
The Apgar score is 6.
It is based on 5 signs evaluated at 1 and 5 minutes after delivery that indicate the physiologic state of the neonate: heart rate over 100 = 2; slow, weak cry = 1; some flexion of extremities = 1; grimace in response to suctioning of the nares = 1; body pink in color with blue extremities = 1.
Total score= 6
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
A. Administering oral morphine is anticipated because it is used to manage withdrawal symptoms in newborns with Neonatal Abstinence Syndrome (NAS..
B. Swaddling is a non-pharmacological intervention that can provide comfort and reduce overstimulation.
C. Administering naloxone is not typically the first line of treatment for NAS and is used in cases of acute opioid overdose, which is not indicated by the information provided.
D. Encouraging the birthing parent to breastfeed may not be appropriate due to the presence of heroin in the system, which can be transmitted to the newborn through breast milk.
E. Continuing NAS scoring is essential to monitor the newborn's condition and response to treatment.
Correct Answer is ["C","E"]
Explanation
A. Deep tendon reflexes are not mentioned in the notes, and there are no indications that they are abnormal or concerning based on the information provided.
B. The respiratory rate is within normal limits and is not significantly abnormal. There are no indications in the notes to suggest respiratory distress or other respiratory issues.
C. The client's symptoms of a severe headache, dizziness upon standing, and inability to remove rings, along with the elevated blood pressure, suggest potential cerebral
manifestations such as preeclampsia. These symptoms warrant further evaluation and intervention by the provider.
D. Fetal heart rate is within normal limits and does not indicate any immediate concerns based on the information provided.
E. The elevated blood pressure (160/96 mm Hg) is a significant finding and may indicate hypertension or preeclampsia, which requires immediate attention from the provider.
F. Gastrointestinal assessment findings are not mentioned in the notes, and there are no
indications of gastrointestinal issues that would warrant reporting to the provider at this time.
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