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?

Answer and Explanation

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.

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Correct Answer is B

Explanation

The correct answer is b) “We do routine hearing screenings on newborns. You’ll know the results before you leave the hospital.”

Choice A reason:

The statement “There is no need to worry about that. Most forms of hearing loss are not inherited” is not entirely accurate. While it is true that not all forms of hearing loss are inherited, genetic factors can play a significant role in hearing loss. Approximately 50-60% of hearing loss in infants is due to genetic causes. Therefore, dismissing the concern without proper screening is not advisable.

Choice B reason:

Routine hearing screenings are conducted on newborns to detect any hearing issues early. These screenings are typically performed before the baby leaves the hospital. The two main types of newborn hearing screenings are Otoacoustic Emissions (OAEs) and Automated Auditory Brainstem Response (AABR). These tests are safe, painless, and can identify hearing loss early, allowing for timely intervention. Early detection is crucial for the development of speech, language, and social skills.

Choice C reason:

Clapping hands loudly to see if the baby startles is not a reliable method to determine hearing ability. While a startle response might indicate that the baby can hear, it does not provide comprehensive information about the baby’s hearing capabilities. Newborn hearing screenings are more accurate and can detect even mild hearing loss.

Choice D reason:

Observing how the baby looks at you when you speak is also not a reliable method to assess hearing. Babies can respond to visual cues and vibrations, which might give the impression that they can hear. However, this method does not provide a definitive assessment of the baby’s hearing ability. Professional hearing screenings are necessary to accurately determine hearing status.

A. 48/min B. 22/min C. 100/min D. 110/min

Correct Answer is A

Explanation

Choice A reason:

A respiratory rate of 48 breaths per minute is within the expected reference range for a newborn. The normal respiratory rate for newborns typically falls between 30 and 60 breaths per minute. This rate ensures that the newborn is receiving adequate oxygen to support their metabolic needs and is a sign of healthy lung function.

Choice B reason:

A respiratory rate of 22 breaths per minute is below the expected reference range for a newborn. Such a low rate may indicate respiratory depression or other underlying issues that require immediate medical attention. Newborns have higher metabolic rates and smaller lung capacities, necessitating a faster breathing rate to meet their oxygen demands.

Choice C reason:

A respiratory rate of 100 breaths per minute is above the expected reference range for a newborn. This condition, known as tachypnea, can be a sign of respiratory distress or other complications such as infection, transient tachypnea of the newborn (TTN), or congenital heart defects. It is essential to monitor and address any causes of elevated respiratory rates to ensure the newborn’s well-being.

Choice D reason:

A respiratory rate of 110 breaths per minute is significantly above the expected reference range for a newborn. This extreme tachypnea is a critical indicator of severe respiratory distress or other serious conditions that require immediate medical intervention. Prompt assessment and treatment are necessary to prevent further complications and ensure the newborn’s health.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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