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?

Answer and Explanation

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

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 B

Explanation

A. While concerning, delayed meconium passage can be monitored for a few more hours.
B. Newborns should void within 24 hours of birth. Failure to void may indicate renal issues or dehydration and requires immediate evaluation.
C. A temperature of 37.5° C is within the normal range for a newborn.
D. Acrocyanosis (bluish discoloration of the hands and feet) is normal in the first 24-48 hours after birth and typically resolves without intervention.

A. "It is due to the newborn's loss of the influence of the maternal hormones." B. "The cause might be too short or infrequent feedings." C. "You might want to offer water supplements between feedings." D. "This might be related to your baby having 3 stools a day."

Correct Answer is B

Explanation

A. Hormone loss doesn’t directly contribute to early weight loss.

B. Breastfed newborns often lose weight in the first few days after birth due to insufficient milk intake from infrequent or short feedings. The nurse should assess feeding patterns and encourage feeding every 2-3 hours.

C. Water supplements are unnecessary and can interfere with breastfeeding.

D. Frequent stools are normal and usually not a significant cause of excessive weight loss.

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 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the newborn nursery is caring for a group of newborns. Which of the following newborns requires immediate intervention?

Correct Answer is B

Explanation

A nurse is completing a home visit to a mother who is 3 days postpartum and breastfeeding her newborn. The mother expresses concern about the amount of weight the newborn has lost since birth. Which of the following is a response the nurse should make?

Correct Answer is B

Explanation

A nurse is planning care for a preterm newborn. Which of the following nursing interventions to promote development should be included in the plan of care?

A 2-day old newborn is observed to be restless, irritable, sucking on its fist, and crying. What action should the nurse take first?

A nurse places a newborn under a radiant heat warmer after birth. The purpose of this action is to prevent which of the following in the newborn?

A 3-day-old infant is slightly jaundiced and has an elevated bilirubin level. What is the most probable cause for these changes?

The nurse recognizes mechanical stimuli involved with the transition to extrauterine pulmonary function includes:

The nurse is caring for a preterm formula fed infant. What finding would be most important to report to the healthcare provider?

Complete the following sentence by using the list of options There are two main hormones that have a significant role in lactation. ______ is responsible for the stimulation of breastmilk production and ______ triggers the let-down reflex.