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. 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.

A. potassium chloride B. ferrous sulfate C. calcium carbonate D. calcium gluconate

Correct Answer is D

Explanation

A. Potassium chloride is not used in the treatment of magnesium sulfate toxicity. Potassium chloride is typically used to correct low potassium levels, but it is not directly related to managing magnesium sulfate toxicity.

B. Ferrous sulfate is an iron supplement, typically used to treat or prevent iron deficiency anemia, and does not play a role in managing magnesium sulfate toxicity.

C. Calcium carbonate is an antacid and is not used to counteract magnesium sulfate toxicity.

D. Calcium gluconate is the correct choice. Magnesium sulfate is used in severe preeclampsia to prevent seizures, but it can cause toxicity, leading to respiratory depression, loss of deep tendon reflexes, or even cardiac arrest. Calcium gluconate is the antidote for magnesium sulfate toxicity and should be readily available to reverse these effects if necessary.

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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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