A nurse observes 5 minutes after delivery that a newborn has a pink trunk and head, bluish hands and feet, and a heart rate of 130/min. He has flexed extremities and a weak, slow cry. The nurse should document what Apgar score for this infant?
5
6
7
8
9
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
A rapid decline in human chorionic gonadotropin (hCG) levels is not typically associated with a hydatidiform mole. In fact, hCG levels are usually elevated in cases of hydatidiform mole due to the abnormal growth of trophoblastic tissue. Elevated hCG levels can lead to symptoms such as severe nausea and vomiting, which are more indicative of this condition.
Choice B Reason:
An irregular fetal heart rate is not a common finding in hydatidiform mole cases. In a complete molar pregnancy, there is no viable fetus, and therefore, no fetal heart rate can be detected. In partial molar pregnancies, there may be some fetal tissue, but it is typically not viable and does not develop a regular heart rate.
Choice C Reason:
Excessive uterine enlargement is a hallmark sign of a hydatidiform mole. This condition causes the uterus to grow more rapidly than it would in a normal pregnancy due to the abnormal proliferation of trophoblastic tissue. This rapid growth can lead to a uterus that is significantly larger than expected for the gestational age.
Choice D Reason:
Profuse, clear vaginal discharge is not specifically associated with hydatidiform mole. While vaginal discharge can increase during pregnancy, the discharge associated with a molar pregnancy is typically dark brown or red due to bleeding from the abnormal tissue. Clear discharge is more commonly associated with normal pregnancy changes or other conditions.
Correct Answer is B
Explanation
Choice A Reason:
Witnessing the signature for informed consent for surgery is important but not the immediate priority. The client’s vital signs indicate potential hemodynamic instability (low blood pressure and high heart rate), which requires prompt intervention to stabilize the client before any surgical procedures can be considered.
Choice B Reason:
Initiating IV access is the priority action. This allows for the administration of fluids and medications, which is crucial in managing the client’s hemodynamic status. The client’s low blood pressure and high heart rate suggest hypovolemia, likely due to significant blood loss. Immediate IV access enables rapid fluid resuscitation and preparation for potential blood transfusions, which are essential to stabilize the client1.
Choice C Reason:
Inserting an indwelling urinary catheter is necessary for monitoring urine output, which is an important indicator of renal perfusion and overall fluid status. However, it is not the immediate priority compared to establishing IV access, which directly addresses the client’s hemodynamic instability.
Choice D Reason:
Preparing the abdominal and perineal areas is a preparatory step for potential surgical intervention. While important, it is not the immediate priority. Stabilizing the client’s condition through IV access and fluid resuscitation takes precedence to ensure the client is in a stable condition for any subsequent procedures.
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