A nurse observes that a newborn has a pink trunk and head, bluish hands and feet, and flexed extremities 5 min after delivery. He has a weak and

slow cry, a heart rate of 130/min, and cries in response to suctioning. The nurse should document what Apgar score for this infant?

Answer and Explanation

The Correct Answer is ["8"]

In the scenario provided, the Apgar score is calculated as follows:

- Appearance (skin color): The newborn has a pink trunk and head with bluish hands and feet, which scores 1 point.
- Pulse (heart rate): The heart rate is 130/min, which is above 100/min, so this scores 2 points.
- Grimace response (reflex irritability): The newborn cries in response to suctioning, which scores 2 points.
- Activity (muscle tone): The newborn has flexed extremities, which scores 2 points.
- Respiration (breathing effort): The cry is weak and slow, which scores 1 point.

Adding these up gives us a total Apgar score of 8 out of a possible 10 points.

Appearance (skin color): Normally, a score of 2 is given if the entire body is pink, 1 for pink body but blue extremities, and 0 if the whole body is pale or blue. The newborn's pink trunk and head with bluish hands and feet warrant a score of 1.

Pulse (heart rate): A score of 2 is given for a heart rate above 100/min, 1 for below 100/min, and 0 if there is no heartbeat. The newborn's heart rate of 130/min earns a score of 2.

Grimace response (reflex irritability): A score of 2 is given for a sneeze, cough, or vigorous cry, 1 for a grimace or feeble cry upon stimulation, and 0 for no response. The newborn's crying in response to suctioning gets a score of 2.

Activity (muscle tone): A score of 2 is given for active motion, 1 for some muscle tone and flexion of extremities, and 0 for limpness. The newborn's flexed extremities give a score of 2.

Respiration (breathing effort): A score of 2 is given for a good, strong cry, 1 for slow or irregular breathing, and 0 for no breathing. The newborn's weak and slow cry results in a score of 1.

The Apgar score helps the healthcare team decide if the newborn needs immediate medical care. A score of 7-10 is generally normal, 4-6 fairly low, and 3 and below critically low. An Apgar score of 8 indicates that the newborn is in good health but may need some medical attention, likely due to the weak and slow cry.

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Correct Answer is D

Explanation

Choice a reason:
The pattern of contractions can be a sign of true labor when they are regular, frequent, and increase in intensity and duration over time. In true labor, contractions do not subside with rest or hydration and become progressively more organized. However, contractions alone can be misleading, as Braxton Hicks contractions may also present a pattern but do not lead to cervical changes.

Choice b reason:
The station of the presenting part refers to the position of the baby's head (or presenting part) in relation to the ischial spines of the mother's pelvis. While the station can indicate how far labor has progressed, it is not a definitive sign of true labor. The station changes as labor progresses, but it can also be affected by other factors such as the baby's position.

Choice c reason:
Rupture of the membranes, commonly known as water breaking, can occur before or during labor. While it is a sign that labor may be imminent, it does not confirm true labor. Some women may experience premature rupture of membranes without contractions or cervical changes.

Choice d reason:
Changes in the cervix, including effacement (thinning) and dilation (opening), are the most reliable signs of true labor. Effacement is measured in percentages, and dilation is measured in centimeters. The cervix must be 100% effaced and dilated to 10 centimeters for childbirth to occur. These changes are a direct result of true labor contractions and indicate that the body is preparing for delivery.

A. There is an increased risk of introducing infection. B. This could initiate preterm labor. C. This could result in profound bleeding. D. There is an increased risk of rupture of the membranes.

Correct Answer is C

Explanation

Choice a reason:

While there is always a risk of introducing infection with an internal examination, this is not the primary concern with placenta previa. Infections are a risk with any invasive procedure, but the precautions taken during a typical internal examination minimize this risk.

Choice b reason:

Initiating preterm labor is a concern with any manipulation of the cervix or uterus during pregnancy. However, at 37 weeks, the pregnancy is considered early-term, and the risk of preterm labor is not the primary concern in the context of placenta previa.

Choice c reason:

The primary reason for avoiding an internal examination in a client with placenta previa is the risk of profound bleeding. With placenta previa, the placenta covers part or all of the cervix. An internal examination could disturb the placenta and lead to significant hemorrhage, which can be life-threatening for both the mother and the fetus.

Choice d reason:

While there is a risk of rupturing the membranes during an internal examination, this is not the primary concern with placenta previa. The main issue is the potential for causing significant bleeding due to the placenta's location over the cervix.

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A nurse observes that a newborn has a pink trunk and head, bluish hands and feet, and flexed extremities 5 min after delivery. He has a weak and slow cry, a heart rate of 130/min, and cries in response to suctioning. The nurse should document what Apgar score for this infant?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor?

Correct Answer is D

Explanation

A nurse is caring for a client who is at 37 weeks of gestation and has placenta previa. The client asks the nurse why the provider does not perform an internal examination. Which of the following explanations of the primary reason should the nurse provide?

Correct Answer is C

Explanation

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A nurse observes that a newborn has a pink trunk and head, bluish hands and feet, and flexed extremities 5 min after delivery. He has a weak and

slow cry, a heart rate of 130/min, and cries in response to suctioning. The nurse should document what Apgar score for this infant?