Erin gives birth to a boy. The nurse notes the following on the baby at 1 minute: heart rate is 138 bpm, loud vigorous crying, spontaneous movement and flexion of the extremities, and pink skin color except for a bluish color of the hands and feet. What Apgar score will be assigned to the baby?
7.
8.
9.
10.
The Correct Answer is B
Choice A reason:
Choice A is incorrect because an Apgar score of 7 would not be appropriate for the described condition. An Apgar score of 7-10 is considered normal for a baby at 1 minute after birth. This baby shows positive signs such as a heart rate of 138 bpm, loud vigorous crying, spontaneous movement and flexion of the extremities, and pink skin color except for a bluish color of the hands and feet, which indicate good overall health.
Choice B reason:
Choice B is the correct answer. An Apgar score of 8 is appropriate for the described condition.
The Apgar score evaluates the baby's condition at 1 minute after birth based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Each criterion is scored from 0 to 2, and the scores are summed up to determine the overall Apgar score. In this case, the baby exhibits positive signs in most of the criteria, resulting in an Apgar score of 8.
Choice C reason:
Choice C is incorrect because an Apgar score of 9 would be too high for the baby's condition. While the baby is exhibiting positive signs, there are still some concerns such as the bluish color of the hands and feet, which may indicate some minor circulation issues.
Choice D reason:
Choice D is also incorrect because an Apgar score of 10 is the highest possible score, and it is typically given to babies who exhibit absolutely no signs of distress or health issues at 1 minute after birth. While this baby shows mostly positive signs, the bluish color of the hands and feet suggests that there might be some minor health concerns, justifying an Apgar score of 8.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
The tonic neck reflex, also called the fencing posture, occurs when a baby's head is turned to one side. The arm and leg on that side stretch out, while the opposite arm and leg bend up at the elbow. This reflex lasts until the baby is about 5 to 7 months old. This reflex matches the description of the question.
Choice B reason:
The Moro reflex, also called the startle reflex, is the baby's reaction to being startled. The cause is often a loud sound, a sudden movement, or even their own cry. As an adult, you may jump or gasp when you are startled. A baby will throw back their head, extend their arms and legs, cry, then pull their arms and legs back in. This reflex does not match the description of the question.
Choice C reason:
The startled reflex is not a distinct reflex in newborns. It is another name for the Moro reflex, which is explained.
Correct Answer is A
Explanation
Choice A reason:
Obtaining blood glucose by heel stick is the appropriate action for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy. These signs are suggestive of hypoglycemia, which is a common and potentially serious condition in newborns. Hypoglycemia can result from various causes, such as maternal diabetes, prematurity, intrauterine growth restriction, or perinatal stress. A heel stick is a simple and quick method to obtain blood samples from newborns for glucose testing.
Choice B reason:
Initiating phototherapy is not the appropriate action for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy. Phototherapy is used to treat hyperbilirubinemia, which is a condition characterized by high levels of bilirubin in the blood. Hyperbilirubinemia can cause jaundice, which is a yellowish discoloration of the skin and eyes. Jaundice does not typically cause diaphoresis, jitteriness, or lethargy in newborns.
Choice C reason:
Monitoring the newborn's blood pressure is not the appropriate action for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy. Blood pressure measurement is not routinely performed in healthy newborns. Blood pressure may be indicated in newborns who have signs of cardiovascular compromise, such as cyanosis, tachycardia, or poor perfusion. Diaphoresis, jitteriness, and lethargy are not specific signs of cardiovascular compromise in newborns.
Choice D reason:
Placing the newborn in a radiant warmer is not the appropriate action for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy. A radiant warmer is a device that provides heat to maintain the newborn's body temperature. A radiant warmer may be used for newborns who are at risk of hypothermia, such as those who are premature, have low birth weight, or have cold stress. Diaphoresis, jitteriness, and lethargy are not specific signs of hypothermia in newborns.
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