A nurse is teaching a class on Apgar scoring to nursing students. Which statement by a student indicates a need for further teaching
“If a newborn has a heart rate below 100 beats per minute, he will receive one point for heart rate.”
“If a newborn has acrocyanosis, he will receive one point for color.”
“If a newborn has active motion of extremities, he will receive two points for muscle tone.”
“If a newborn has a vigorous cry when stimulated, he will receive two points for reflex irritability.”.
The Correct Answer is B
This is wrong because acrocyanosis means that the body is pink but the extremities are blue, which indicates poor circulation. A normal Apgar score for color is two points, which means that the baby is pink all over.
Choice A is correct because a heart rate below 100 beats per minute is considered moderately abnormal and receives one point.
Choice C is correct because active motion of extremities indicates good muscle tone and receives two points.
Choice D is correct because a vigorous cry when stimulated indicates good reflex irritability and receives two points.
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Correct Answer is D
Explanation
Based on the Apgar score components provided, the newborn would likely receive the following scores:
- Appearance (color):Pink all over -2 points
- Pulse (heart rate):120 bpm -2 points
- Grimace (reflex irritability):Makes a strong cry -2 points
- Activity (muscle tone):Active movement -2 points
- Respiration:Deep, regular breaths -2 points
Adding these together, the newborn’s Apgar score would be10, which indicates the baby is in excellent condition following delivery.
The Apgar score is a quick assessment method used to evaluate a newborn baby’s health immediately after birth and again 5 minutes later. It was created by Dr. Virginia Apgar in 1952 and is an important tool for healthcare professionals to determine the immediate physical condition of a newborn and the need for any urgent medical care.
Here’s what the Apgar score measures, with each category receiving a score from 0 to 2:
- Appearance (color):Checks the baby’s skin tone
- Pulse (heart rate):Measures the heart rate
- Grimace (reflex irritability):Assesses the reflex response
- Activity (muscle tone):Evaluates muscle tone and movement
- Respiration:Observes the breathing effort and regularity
The significance of the Apgar score lies in its ability to provide a standardized and rapid assessment of a newborn’s vital signs and immediate health. It helps to quickly identify babies who are struggling and may need additional medical attention.However, it’s important to note that the Apgar score is not designed to predict long-term health outcomes or neurological development.It’s one of many assessments used to understand a baby’s condition at birth.
Here’s a table that outlines the Apgar score criteria and the points assigned for each:
Table
Criteria |
0 Points |
1 Point |
2 Points |
Appearance (Color) |
Blue or pale all over |
Body pink, extremities blue |
Pink all over |
Pulse (Heart Rate) |
Absent |
Less than 100 bpm |
100 bpm or more |
Grimace Response |
No response to stimulation |
Grimace or weak cry |
Strong cry, pulls away |
Activity (Muscle Tone) |
Limp |
Some flexion of extremities |
Active motion |
Respiration |
Absent |
Slow or irregular breathing |
Good, strong cry |
The Apgar score is calculated at 1 minute and 5 minutes after birth. Each of the five criteria is scored between 0 and 2, with a maximum total score of 10. This scoring system helps medical professionals quickly assess the newborn’s general condition and determine if any immediate medical intervention is needed. A score of 7 to 10 is considered normal, 4 to 6 fairly low, and 3 and below critically low.
Correct Answer is D
Explanation
Darkening of the mucosa.This is an expected variation for an older adult client because the melanin production increases with age.
Some possible explanations for the other choices are:
• Choice A.White patches on the tongue could indicate candidiasis, an oral fungal infection.
• Choice B.Bleeding of the gums could indicate gingivitis, periodontitis, or vitamin C deficiency.
• Choice C.Red spots on the hard palate could indicate petechiae, which are small hemorrhages caused by trauma, infection, or bleeding disorders.
Normal ranges for oral mucosa color vary depending on the skin tone and ethnicity of the client.Generally, the oral mucosa should be pink and moist without lesions or discolorations.
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