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 know to call my health care provider right away if I start to bleed again." This statement reflects the woman's understanding of the importance of monitoring for any complications such as bleeding and taking prompt action, which is appropriate for expectant management.

B. "My mother lives next door and can drive me here if necessary." This indicates that the woman has support at home, which is important for her ability to access care if needed. It suggests a good support system for managing the pregnancy.

C. "I realize the importance of following the instructions for my care." This shows that the woman understands the need for careful adherence to her care plan, which is a positive sign that she is well-informed and prepared for home care.

D. "I have a toddler and preschooler at home who need my attention." This statement raises concern because caring for young children at home might pose a risk to the woman’s health and safety. It can make it more challenging for her to adhere to the prescribed bed rest or reduced activity level needed for managing placenta previa, especially if she needs to be closely monitored for bleeding or complications. Therefore, this statement suggests that home care might not be appropriate in this situation.

A. Wrap the newborn in a blanket. B. Put a hat on the newborn's head. C. Check the newborn's temperature. D. Dry the newborn thoroughly.

Correct Answer is D

Explanation

A. Wrap the newborn in a blanket helps maintain body heat after the initial drying and stimulation but is not the first priority in thermoregulation.
B. Put a hat on the newborn's head also helps prevent heat loss, particularly from the head, which is a major site of heat loss in newborns. However, this should be done after drying to avoid trapping moisture.
C. Check the newborn's temperature is important but should be done after immediate measures to prevent heat loss have been taken.
D. Dry the newborn thoroughly is the first and most critical step in preventing evaporative heat loss, which is the primary cause of newborn heat loss immediately after birth. Removing wet amniotic fluid from the skin helps stabilize temperature effectively.

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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 with placenta previa is being treated with expectant management. The woman and fetus are stable. The nurse is assessing the woman for possible discharge home. Which statement by the woman would suggest to the nurse that home care might be inappropriate?

Correct Answer is D

Explanation

After the birth of a newborn, which action would the nurse do first to assist in thermoregulation?

Correct Answer is D

Explanation

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