A nurse is caring for a newborn who has a temperature of 36.1°C (97°F), heart rate of 140/min, respiratory rate of 50/min, muscle tone of 1, and reflex irritability of 1.
What is the newborn’s APGAR score at 1 minute?
4
5
6
7
The Correct Answer is B
5. The APGAR score is a method of assessing the health of a newborn based on five criteria: appearance (skin color), pulse (heart rate), grimace (reflex irritability), activity (muscle tone), and respiration (breathing rate and effort).
Each criterion is scored from 0 to 2, with a total score ranging from 0 to 10.
A higher score indicates a better condition of the newborn.
The newborn in the question has a score of 1 for appearance (pale or blue extremities), 1 for pulse (heart rate below 160/min), 1 for grimace (minimal response to stimulation), 1 for activity (some flexion of extremities), and 1 for respiration (slow or irregular breathing).
The sum of these scores is 5.
Choice A is wrong because a score of 4 would mean that the newborn has a score of 0 for one of the criteria, which is not the case.
Choice C is wrong because a score of 6 would mean that the newborn has a score of 2 for one of the criteria, which is not the case.
Choice D is wrong because a score of 7 would mean that the newborn has a score of 2 for two of the criteria, which is not the case.
The normal ranges for each criterion are:
• Appearance: 0 (blue or pale all over), 1 (pink body but blue extremities), or 2 (pink all over).
• Pulse: 0 (absent), 1 (below 100/min), or 2 (above 100/min).
• Grimace: 0 (no response to stimulation), 1 (grimace or weak cry), or 2 (vigorous cry).
• Activity: 0 (limp or flaccid), 1 (some flexion of extremities), or 2 (active movement).
• Respiration: 0 (absent), 1 (slow or irregular), or 2 (good and regular).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
5. The APGAR score is a method of assessing the health of a newborn based on five criteria: appearance (skin color), pulse (heart rate), grimace (reflex irritability), activity (muscle tone), and respiration (breathing rate and effort).
Each criterion is scored from 0 to 2, with a total score ranging from 0 to 10.
A higher score indicates a better condition of the newborn.
The newborn in the question has a score of 1 for appearance (pale or blue extremities), 1 for pulse (heart rate below 160/min), 1 for grimace (minimal response to stimulation), 1 for activity (some flexion of extremities), and 1 for respiration (slow or irregular breathing).
The sum of these scores is 5.
Choice A is wrong because a score of 4 would mean that the newborn has a score of 0 for one of the criteria, which is not the case.
Choice C is wrong because a score of 6 would mean that the newborn has a score of 2 for one of the criteria, which is not the case.
Choice D is wrong because a score of 7 would mean that the newborn has a score of 2 for two of the criteria, which is not the case.
The normal ranges for each criterion are:
• Appearance: 0 (blue or pale all over), 1 (pink body but blue extremities), or 2 (pink all over).
• Pulse: 0 (absent), 1 (below 100/min), or 2 (above 100/min).
• Grimace: 0 (no response to stimulation), 1 (grimace or weak cry), or 2 (vigorous cry).
• Activity: 0 (limp or flaccid), 1 (some flexion of extremities), or 2 (active movement).
• Respiration: 0 (absent), 1 (slow or irregular), or 2 (good and regular).
Correct Answer is C
Explanation
The anterior fontanelle is bulging and tense when the newborn cries.This is an abnormal finding that should be reported to the provider as it may indicate increased intracranial pressure or intracranial and extracranial tumors.
Choice A is wrong because the anterior fontanelle is normally diamond-shaped and 2 cm wide.
Choice B is wrong because the posterior fontanelle is normally triangular and 0.5 cm wide.
Choice D is wrong because the posterior fontanelle normally closes by 8 weeksand may not be palpable at six weeks.
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