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 D

Explanation

A. "I need to call my doctor if my temperature increases." This is an appropriate and accurate statement. An elevated temperature could be a sign of infection, which is a risk for women with preterm prelabor rupture of membranes (PPROM). The woman should contact her healthcare provider if her temperature rises, as infection can lead to complications.

B. "I can shower, but I shouldn't take a tub bath." This is also correct. After PPROM, the woman is typically allowed to shower to maintain personal hygiene, but taking a tub bath can increase the risk of infection by allowing bacteria to enter the vagina.

C. "I need to keep a close eye on how active my baby is each day." This is a correct and helpful statement. Monitoring fetal movement is important for assessing the baby's well-being. Decreased fetal movement could indicate a potential problem, and the woman should contact her provider if she notices reduced activity.

D. "It's okay for my husband and me to have sexual intercourse." This statement indicates a need for additional teaching. Sexual intercourse is typically not recommended after PPROM because it could increase the risk of infection, especially if the membranes are ruptured. The woman should avoid sexual activity until advised otherwise by her healthcare provider.

A. clear liquid diet B. administration of labetalol C. small frequent meals D. nothing by mouth

Correct Answer is D

Explanation

A. Clear liquid diet may be appropriate later in treatment once symptoms improve, but it is not typically initiated immediately in a client with severe hyperemesis gravidarum, especially if they are unable to keep any fluids down.

B. Administration of labetalol is used to treat hypertension, particularly in preeclampsia, and is not related to the treatment of hyperemesis gravidarum.

C. Small frequent meals are part of long-term management or mild cases, but for severe hyperemesis gravidarum requiring hospitalization, oral intake is usually withheld initially.

D. Nothing by mouth (NPO) is correct. In severe hyperemesis gravidarum, the client is often kept NPO to rest the gastrointestinal tract and prevent further vomiting. Intravenous (IV) fluids, electrolytes, and sometimes antiemetic medications are administered to manage dehydration and nutritional deficits before gradually resuming oral intake.

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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

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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