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 A
Explanation
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.
Correct Answer is A
Explanation
Choice A reason:
“The cause might be too short or infrequent feedings.”: Newborns typically lose weight in the first few days after birth, which is normal. However, if the weight loss is significant, it could be due to inadequate feeding. Breastfed newborns should be fed 8-12 times in 24 hours to ensure they are getting enough milk. Short or infrequent feedings can lead to insufficient intake, resulting in weight loss2. Ensuring proper latch and feeding techniques can help address this issue.
Choice B reason:
“It is due to the newborn’s loss of the influence of the maternal hormones.”: While maternal hormones do influence the newborn, their loss is not a primary cause of significant weight loss. The initial weight loss is more related to fluid loss and the transition to breastfeeding.
Choice C reason:
“This might be related to your baby having 3 stools a day.”: Frequent stools are common in newborns, especially those who are breastfed. While it can contribute to weight loss, it is usually not the main cause of significant weight loss. Monitoring the baby’s feeding and ensuring they are getting enough milk is more critical.
Choice D reason:
“You might want to offer water supplements between feedings.”: Offering water supplements to a newborn is not recommended, especially for breastfed babies. Breast milk provides all the necessary hydration and nutrients. Introducing water can interfere with breastfeeding and reduce the baby’s intake of breast milk, potentially leading to further weight loss.
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