An infant boy was born just a few minutes ago.
The nurse is conducting the initial assessment which includes the Apgar score.
The Apgar assessment is performed:
At least twice, 1 minute and 5 minutes after birth.
Every 15 minutes during the newborn's first hour after birth.
Once by the obstetrician, just after the birth.
Only if the newborn is in obvious distress.
The Correct Answer is A
Choice A rationale
The Apgar score is a rapid assessment of the newborn's immediate transition to extrauterine life. It evaluates five signs: Appearance (color), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration. The initial assessments are standardized at 1 and 5 minutes after birth to track improvement or deterioration.
Choice B rationale
The Apgar score is performed at 1 and 5 minutes as a baseline and assessment of immediate transition. It is repeated at 10 minutes only if the 5-minute score is 6 or less. Assessing it every 15 minutes during the first hour is not the standardized practice for this specific tool.
Choice C rationale
Although the obstetrician or nurse initially performs the Apgar, it is a timed assessment and is standardly performed by the nurse or healthcare provider at least twice (at 1 and 5 minutes). The nurse's role is to ensure the 5-minute score is recorded and to continue monitoring.
Choice D rationale
The Apgar assessment is a routine, standardized component of the initial newborn assessment for all infants. It serves as an objective method to determine the need for immediate resuscitation (if 1-minute score is low) or continued close observation, not only for obvious distress. —.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice C rationale
Seldom making eye contact with the newborn can indicate a lack of emotional engagement and difficulty forming an attachment bond, which is a critical process for healthy infant development. Direct eye contact is a foundational element in early parent-infant communication and bonding, signaling maternal interest and availability, making its absence a potential sign of a maladaptive attachment behavior requiring further assessment and intervention by the nurse.
Choice A rationale
Telling visitors how well her son is feeding demonstrates that the mother is actively observing and engaging with her infant's basic care and well-being. This behavior reflects a healthy maternal focus on the baby's needs and a proud, positive perception of her infant, which are all characteristics associated with the development of a secure and adaptive parent-infant attachment bond.
Choice B rationale
Talking and cooing to her son is a normal, adaptive, and positive communication behavior that encourages infant sensory development and reciprocal interaction. This use of "motherese" or baby-talk is instinctively designed to capture the infant's attention, facilitate language development, and strengthen the emotional connection necessary for a secure attachment to form between the parent and the infant.
Choice D rationale
Cuddling her son close to her is an integral tactile bonding behavior that provides the infant with essential physical closeness, warmth, and a feeling of security. This physical proximity promotes the release of oxytocin, a hormone critical for maternal feelings and bonding, and signifies a healthy desire for physical contact, which is highly indicative of an adaptive and affectionate attachment. —.
Correct Answer is B
Explanation
Choice A rationale
Frequent and consistent breast pumping is essential to establish and maintain an adequate milk supply, particularly for mothers of preterm infants. Pumping approximately every 2 to 3 hours, or 8 to 12 times in a 24-hour period, better mimics a newborn's feeding frequency and is crucial for stimulating prolactin release and milk synthesis, more so than the 4 to 6 hour interval which risks decreasing supply.
Choice B rationale
Breast milk contains high concentrations of whey protein, which forms a soft, easily digestible curd in the infant's stomach, facilitating gastric emptying. Furthermore, human milk contains lipase, which aids in fat digestion, and human milk oligosaccharides (HMOs), which act as prebiotics to promote beneficial gut flora, all making it superior to formula.
Choice C rationale
Alcohol, including that consumed in wine, passes readily into breast milk. Although the concentration in milk mirrors that in the mother's blood, the alcohol can impair the infant's motor development, disrupt sleep patterns, and potentially inhibit the milk ejection reflex (let-down), thereby reducing the volume of milk obtained during the pumping session.
Choice D rationale
Mothers of preterm infants should pump to establish a full milk supply, which often exceeds the initial small volumes the premature infant can tolerate. Pumping frequently to empty the breasts fully signals the body to produce more milk, supporting the ultimate goal of providing a full volume of human milk as the infant matures and increases intake.
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