The nurse notes that a newborn, who is 5 minutes old, exhibits the following characteristics: pink body with blue hands and feet, heart rate 108 bpm. respiratory rate 36 per minute, some flexion, and a vigorous cry with stimulation. What does the nurse determine the baby's APGAR score to be?
9
7
6
8
The Correct Answer is D
A. Heart Rate: 108 bpm = 2 points, Respiratory Effort: Regular rate with a cry = 2 points, Muscle Tone: Some flexion = 1 point, Reflex Irritability: Vigorous cry with stimulation = 2 points, Color: Pink body, blue extremities (acrocyanosis) = 1 point: Total APGAR Score: 8
B. A. Heart Rate: 108 bpm = 2 points, Respiratory Effort: Regular rate with a cry = 2 points, Muscle Tone: Some flexion = 1 point, Reflex Irritability: Vigorous cry with stimulation = 2 points, Color: Pink body, blue extremities (acrocyanosis) = 1 point: Total APGAR Score: 8
C. A. Heart Rate: 108 bpm = 2 points, Respiratory Effort: Regular rate with a cry = 2 points, Muscle Tone: Some flexion = 1 point, Reflex Irritability: Vigorous cry with stimulation = 2 points, Color: Pink body, blue extremities (acrocyanosis) = 1 point: Total APGAR Score: 8
D. A. Heart Rate: 108 bpm = 2 points, Respiratory Effort: Regular rate with a cry = 2 points, Muscle Tone: Some flexion = 1 point, Reflex Irritability: Vigorous cry with stimulation = 2 points, Color: Pink body, blue extremities (acrocyanosis) = 1 point: Total APGAR Score: 8
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Explanation
Respiratory Status: The newborn is exhibiting signs of respiratory distress, including a respiratory rate of 100/min, grunting, nasal flaring, and substernal retractions. These findings indicate compromised respiratory function, which requires immediate attention to prevent hypoxemia or respiratory failure. The diffuse radiopaque areas on the chest x-ray suggest a condition like transient tachypnea of the newborn (TTN) or respiratory distress syndrome (RDS), common in low-birth-weight infants.
Temperature: After stabilizing the respiratory status, addressing the newborn’s temperature is important. The temperature of 36.3°C (97.3°F) indicates mild hypothermia, which can further compromise respiratory function and glucose metabolism if not corrected. Warming the infant with skin-to-skin contact or using a radiant warmer is necessary to maintain thermoregulation.
Correct Answer is D
Explanation
A. Intraventricular hemorrhage presents with neurological signs like apnea or seizures, not primarily gastrointestinal symptoms.
B. Increased gastric residuals alone may indicate a need for tube placement, but the full symptom set suggests NEC.
C. Overstimulation may cause irritability but does not typically result in bloody stools or abdominal distension.
D. NEC is a life-threatening gastrointestinal disorder in preterm infants characterized by intestinal inflammation, abdominal distension, lethargy, bloody stools, and increased gastric residuals. Immediate intervention is necessary.
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