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

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Correct Answer is D

Explanation

A. Washing the area aggressively is not necessary.

B. Notification of the healthcare provider is unnecessary for this benign finding.

C. Milia are not a sign of infection.

D. The white spots are milia, a common and benign finding in newborns. Parents should avoid pinching or poking them as they will resolve spontaneously.

A. Elevated hemoglobin and bilirubin. B. Acrocyanosis and unstable thermoregulation. C. Generalized mottling and uncoordinated suck. D. Lethargy and pallor.

Correct Answer is D

Explanation

A. Elevated hemoglobin and bilirubin: These findings are more consistent with jaundice or polycythemia, not sepsis.
B. Acrocyanosis and unstable thermoregulation: Acrocyanosis is normal in newborns; thermoregulation issues are concerning but nonspecific for sepsis.
C. Generalized mottling and uncoordinated suck: These may occur in sepsis but are less specific compared to lethargy and pallor.
D. Lethargy and pallor: These are classic signs of neonatal sepsis, a potentially life-threatening condition requiring immediate intervention.

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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?

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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?

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