The nurse is caring for an infant delivered one minute ago. The infant has no spontaneous respirations, no response to stimulus, is limp, pale, and has a heart rate of 99 beats per minute.
How will the nurse document this infant's APGAR Score?
Enter number only (no units).
The Correct Answer is ["1"]
The APGAR score assesses five criteria: Appearance (skin colour), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration (breathing effort). Each criterion is scored from 0 to 2, with a maximum total score of 10.
- Appearance: The infant is pale, which scores 0.
- Pulse: The heart rate is 99 beats per minute, which scores 1 (as it is below 100).
- Grimace: No response to stimulus, which scores 0.
- Activity: The infant is limp, which scores 0.
- Respiration: No spontaneous respirations, which scores 0.
Summing these scores gives a total APGAR score of 1.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Anencephaly is a severe neural tube defect where a major portion of the brain, skull, and scalp is missing. It does not present with a tuft of hair on the lumbosacral area.
Choice B reason: Spina bifida, specifically spina bifida occulta, is associated with a small tuft of hair on the lumbosacral area. This condition involves a defect in the spinal column where the bones do not close completely, but the spinal cord and nerves are usually not affected.
Choice C reason: Meningocele is a type of spina bifida where the protective membranes (meninges) protrude through an opening in the spine, forming a sac filled with cerebrospinal fluid. While it involves a spinal defect, it does not typically present with a tuft of hair.
Choice D reason: Myelomeningocele is the most severe form of spina bifida where the spinal cord and nerves protrude through an opening in the spine. This condition often results in more significant neurological deficits and is not specifically associated with a tuft of hair on the lumbosacral area.
Correct Answer is C
Explanation
Choice A reason: Burping the baby on their shoulder is a common and effective method to help release air that the baby may have swallowed during feeding. It does not require further teaching.
Choice B reason: Swaddling the baby in the bassinet can help the baby feel secure and sleep better. However, it is important to ensure that the swaddle is not too tight and that the baby's hips can move freely to prevent hip dysplasia.
Choice C reason: Placing the baby on their side for sleep is not recommended due to the increased risk of sudden infant death syndrome (SIDS). The safest sleep position for babies is on their back, on a firm mattress, without any loose bedding or soft toys.
Choice D reason: Waking the baby for feedings is often necessary, especially in the early weeks, to ensure that the baby gets enough nutrition and maintains an adequate weight gain. It does not require further teaching.
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