The nurse is assessing Apgar score on a newborn. What will be evaluated? (Select all that apply.)
Heart rate
Respiration
Color
Reflexes
Weight
Correct Answer : A,B,C,D
A. Heart rate: Heart rate is a primary component of the Apgar score, with higher rates indicating better cardiovascular adaptation to extrauterine life. It is assessed immediately after birth and contributes significantly to the total score.
B. Respiration: Respiratory effort, including the rate and quality of breathing, is evaluated for the Apgar score. Strong, regular respirations indicate good respiratory adaptation, while weak or absent effort suggests the need for intervention.
C. Color: Skin color is assessed, including overall appearance and extremity coloration. A pink body and extremities contribute positively to the Apgar score, while pallor or cyanosis can lower the score and indicate hypoxia.
D. Reflexes: Reflex irritability, often tested by response to stimulation such as a mild pinch, is included in the Apgar score. A vigorous cry or active movement indicates good neurologic responsiveness.
E. Weight: Birth weight is not part of the Apgar assessment. While important for overall neonatal health and care planning, it does not contribute to the Apgar score.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["200"]
Explanation
Calculation:
Total volume = 100 mL.
Infusion time = 30 minutes
= 30 minutes / 60 minutes/hour
= 0.5 hours.
- Calculate the infusion rate in milliliters per hour (mL/hr).
Infusion rate (mL/hr) = Total volume (mL) / Total time (hr)
= 100 mL / 0.5 hr
= 200 mL/hr.
Correct Answer is D
Explanation
A. Estrogen: Estrogen plays a role in fetal development and preparation for labor but is not directly responsible for preventing respiratory distress syndrome. Its levels do not determine lung maturity or surfactant production.
B. Hyaline: Hyaline refers to the hyaline membranes seen in the lungs of infants with respiratory distress syndrome, not a deficiency. These membranes result from alveolar collapse and injury, not a causative factor.
C. Protein: While protein is essential for overall growth and development, a general protein deficiency does not directly cause respiratory distress syndrome. Lung immaturity is related specifically to surfactant production.
D. Surfactant: Respiratory distress syndrome occurs in preterm infants due to insufficient pulmonary surfactant, which reduces alveolar surface tension. Without adequate surfactant, alveoli collapse with each breath, leading to impaired gas exchange and respiratory difficulty.
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