The nurse is performing an Apgar score on a newborn at 5 minutes after birth. The infant has a heart rate of 100, pink body and blue hands, active motion, and a strong lust cry and respirations. What is the Apgar score that should be assigned to this infant?

Answer and Explanation

The Correct Answer is D

A. A score of 7 would be given if the infant’s heart rate was 100, but with less than optimal responses for color, muscle tone, and respiratory effort. However, this baby demonstrates strong responses in all categories.

B. A score of 8 would indicate that the baby has no signs of cyanosis and perfect responses in all categories, but since the infant has blue hands, it scores slightly lower (1 point less for color).

C. A score of 5 would indicate more significant distress, with poor color, respiratory effort, and muscle tone. This infant is showing good signs of adaptation.

D. The Apgar score is calculated based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. The infant in the scenario has:Heart rate of 100 (score 2)Pink body and blue hands (score 1 for color—because the baby is not fully pink, indicating some cyanosis in the extremities)Active motion (score 2 for muscle tone)Strong lusty cry (score 2 for reflex irritability/responsiveness to stimuli)
Good respirations (score 2)Adding these scores (2 + 1 + 2 + 2 + 2), the total is 9.

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Correct Answer is C

Explanation

A. Oligohydramnios is more commonly associated with conditions like fetal growth restriction or placental insufficiency, and it is less common in twin pregnancies, which are actually more prone to polyhydramnios, especially in cases of twin-to-twin transfusion syndrome.

B. Chorioamnionitis is an infection of the fetal membranes, which can occur in any pregnancy, particularly with prolonged rupture of membranes, but it is not uniquely or especially linked to twin pregnancies.

C. Preeclampsia is correct. Women carrying twins (or other multiples) are at significantly higher risk for developing preeclampsia due to the increased placental mass and associated vascular demands. Nurses should be particularly vigilant in monitoring for signs like elevated blood pressure, proteinuria, edema, and headaches in these clients.

D. Post-term labor is less likely in twin pregnancies, as multiples are more often born preterm, not post-term, due to uterine overdistension and other complications.

A. birth trauma. B. stork bites. C. milia D. Mongolian spots

Correct Answer is D

Explanation

A. Birth trauma typically refers to physical injuries sustained during delivery, such as bruising or fractures. Bluish markings across the lower back are not indicative of birth trauma.
B. Stork bites are reddish or pinkish marks, usually found on the nape of the neck, eyelids, or forehead. They are vascular birthmarks and are not bluish in color.
C. Milia refers to small white cysts found on a newborn's face, usually on the nose, chin, or forehead, caused by blocked sebaceous glands. It is not associated with bluish markings.
D. Mongolian spots are bluish or purplish birthmarks commonly found on the lower back or buttocks of infants, especially those with darker skin. These are normal and typically fade over time.

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The nurse is performing an Apgar score on a newborn at 5 minutes after birth. The infant has a heart rate of 100, pink body and blue hands, active motion, and a strong lust cry and respirations. What is the Apgar score that should be assigned to this infant?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A woman pregnant with twins comes to the clinic for an evaluation. While assessing the client, the nurse would be especially alert for signs and symptoms for which potential problem?

Correct Answer is C

Explanation

During a physical assessment of a newborn, the nurse observes bluish markings across the newborn's lower back. The nurse interprets this finding as:

Correct Answer is D

Explanation

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