A nurse is preparing to assess a newborn who is post-term. Which of the following findings should the nurse expect? (Select all that apply)

Choice A Reason:

The Apgar score is a quick test performed on a newborn at 1 and 5 minutes after birth. The 5 criteria assessed are Appearance (skin color), Pulse (heart rate), Grimace response (reflexes), Activity (muscle tone), and Respiration (breathing effort). Each criterion is scored on a scale of 0 to 2, with 2 being the best score. The total score is calculated by adding the scores of all five criteria, with a maximum possible score of 10.

For this newborn:

• Appearance: The newborn has a pink trunk and head but bluish hands and feet, which scores 1 point12.

• Pulse: The heart rate is 130/min, which scores 2 points1.

• Grimace: The newborn has a weak, slow cry, which scores 1 point3.

• Activity: The newborn has flexed extremities, which scores 1 point3.

• Respiration: The newborn has a weak, slow cry, which scores 1 point3.

Adding these scores: 1 (Appearance) + 2 (Pulse) + 1 (Grimace) + 1 (Activity) + 1 (Respiration) = 6.

Choice B Reason:

This choice is correct. As explained above, the total Apgar score for this newborn is 6. The breakdown of the scores is as follows:

• Appearance: 1 point for pink trunk and head, bluish hands and feet.

• Pulse: 2 points for a heart rate of 130/min.

• Grimace: 1 point for a weak, slow cry.

• Activity: 1 point for flexed extremities.

• Respiration: 1 point for a weak, slow cry.

Choice C Reason:

This choice is incorrect. A score of 7 would require higher scores in one or more of the criteria. For example, if the newborn had a strong cry (2 points for Grimace and Respiration) or if the entire body was pink (2 points for Appearance), the total score would be higher.

Choice D Reason:

This choice is incorrect. A score of 8 would require even higher scores in the criteria. For instance, if the newborn had a strong cry and the entire body was pink, the total score would be 8 or higher.

Choice E Reason:

This choice is incorrect. A score of 9 would require almost perfect scores in all criteria, which is not the case for this newborn. The newborn’s weak, slow cry and bluish hands and feet lower the total score.

Choice A reason:

Dyspnea: Dyspnea, or difficulty breathing, is a serious adverse effect that should be reported immediately. Terbutaline can cause pulmonary edema, a condition where fluid accumulates in the lungs, leading to severe breathing difficulties. This side effect is critical and requires prompt medical attention to prevent further complications.

Choice B reason:

Headaches: While headaches are a common side effect of terbutaline, they are generally not considered severe enough to require immediate reporting unless they are persistent or unusually intense. Headaches can be managed with over-the-counter pain relief and do not typically indicate a serious problem.

Choice C reason:

Nervousness: Nervousness is another common side effect of terbutaline. It is usually mild and does not require immediate medical intervention. However, if the nervousness is severe or accompanied by other symptoms, it should be discussed with a healthcare provider.

Choice D reason:

Tremors: Tremors are a known side effect of terbutaline and are usually not severe. They occur due to the medication’s action on the nervous system. While they can be bothersome, they are not typically dangerous and do not require urgent reporting unless they are severe or persistent.