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 B

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. 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 8.

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. A score of 9 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).

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Deficient fluid volume is not the priority concern at this time. While newborns are at risk for dehydration, there are no indications in the assessment (such as dry mucous membranes or poor feeding) that would suggest deficient fluid volume as the immediate priority.

B. Risk for infection is a concern for all newborns, especially in the first hours of life. However, the information provided does not suggest signs of infection such as fever, lethargy, or abnormal skin color.

C. Impaired parenting may be a concern later on if the parents show difficulty bonding or caring for the infant. However, this is not the immediate priority based on the infant's current assessment.

D. Hypothermia is the priority. The infant’s axillary temperature of 95.8° F (35.4° C) is below the normal range for a newborn, which is typically between 97.7° F (36.5° C) and 99.5° F (37.5° C). Hypothermia in newborns can lead to complications such as respiratory distress, metabolic instability, and increased risk for infection. Immediate interventions, such as warming the infant and ensuring a warm environment, are necessary to prevent further complications.

A. Advance maternal age B. Polyhydramnios C. Macrosomia D. Preterm birth

Correct Answer is C

Explanation

A. Advanced maternal age may increase the risk of certain pregnancy complications, but it is not specifically associated with shoulder dystocia. Other factors, such as fetal size, are more directly related to shoulder dystocia.

B. Polyhydramnios (excess amniotic fluid) can sometimes be associated with complications during labor, but it is not the primary risk factor for shoulder dystocia. The condition most often involves difficulties with the fetal position or size rather than the amount of fluid.

C. Macrosomia (a large baby, typically defined as a birth weight over 8 pounds 13 ounces or 4000g) is the primary risk factor for shoulder dystocia. Shoulder dystocia occurs when the baby’s shoulders become stuck during delivery, often due to the larger size of the baby. The baby’s shoulders may be too broad to pass through the birth canal easily, which increases the likelihood of this complication.

D. Preterm birth is not a significant risk factor for shoulder dystocia. Preterm babies are typically smaller and less likely to encounter the same birth canal obstruction issues associated with shoulder dystocia.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8° F (35.4° C), an apical pulse of 114 beats per minute, and a respiratory rate of 60 breaths per minute. The nurse would identify which area as the priority?

Correct Answer is D

Explanation

The nurse knows that the occurrence of shoulder dystocia during labor is most likely related to which of the following?

Correct Answer is C

Explanation

A client with severe hyperemesis gravidarum is admitted to the facility after being cared for at home without success. What would the nurse expect to include in the client's plan of care?

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?

After teaching an in-service program to a group of nurses working in newborn nursery about a neutral thermal environment, the nurse determines that the teaching was successful when the group identifies which process as the newborn's primary method of heat production?

A nurse is providing care to a postpartum woman. Which of the following behavior by the client would indicate the client is in the Taking in phase?

A client with severe preeclampsia is receiving magnesium sulfate as part of the treatment plan. To ensure the client's safety, which compound would the nurse have readily available?

A client is suspected of having a ruptured ectopic pregnancy. Which assessment would the nurse identify as the priority?

A nurse is teaching a new mother about breastfeeding. The nurse determines that the teaching was successful when the woman identifies which hormone as responsible for milk let-down?