Which of the following components are used to calculate the Apgar score for a newborn?
(Select All that Apply.)

Respiratory rate

Body temperature

Muscle tone

Reflexes

Blood pressure

Heart rate

Answer and Explanation

Correct Answer : A,C,D,F

A. Respiratory rate: Respiratory effort is a key Apgar component, assessing the newborn’s ability to breathe effectively. A strong cry (2 score) indicates good respiratory effort and scores higher, while absent (0 score) or weak (1 score) respiration reflects respiratory compromise.

B. Body temperature: Body temperature is not part of the Apgar score. While important for overall newborn assessment and thermoregulation, it does not directly reflect the infant's immediate adaptation to extrauterine life in the first minute.

C. Muscle tone: Muscle tone evaluates the infant's level of flexion and spontaneous movement. A newborn with active motion and flexed extremities receives a 2 score, indicating healthy neuromuscular function and oxygenation, some flexion receives a 1 score while zero reflects a zero score.

D. Reflexes: Reflex irritability is measured by the newborn’s response to stimuli, such as suctioning or a mild slap on the sole. A prompt cry or withdrawal indicates intact neurologic responsiveness and earns a higher Apgar score.

E. Blood pressure: Blood pressure is not evaluated in the Apgar scoring system. It requires equipment and time that are not practical in the rapid assessment immediately after birth, unlike observable and quickly assessed criteria.

F. Heart rate: Heart rate is the most critical element of the Apgar score. It reflects cardiovascular stability, with scores ranging from 0 for absent to 2 for rates over 100 beats per minute, indicating effective circulatory function.

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Correct Answer is B

Explanation

A. It prevents the formation of Rh antibodies in newborns who are Rh positive: Rh immunoglobulin is administered to the mother, not the newborn. It does not prevent antibody formation in the infant; instead, it prevents maternal sensitization that can harm future pregnancies.

B. It prevents the formation of Rh antibodies in mothers who are Rh negative: Rh(D) immunoglobulin works by suppressing the maternal immune response to fetal Rh-positive red blood cells. This prevents the formation of maternal anti-D antibodies, which could attack fetal red cells in future pregnancies.

C. It destroys Rh antibodies in mothers who are Rh negative: Rh immunoglobulin does not destroy antibodies already formed. If maternal sensitization has occurred and anti-D antibodies are already present, RhIg is no longer effective or indicated.

D. It destroys Rh antibodies in newborns who are Rh positive: RhIg has no role in treating or affecting the newborn’s immune system. It acts only in the Rh-negative mother to prevent alloimmunization after potential fetal-maternal blood mixing.

A. Cluster the newborn's care activities. B. Position the newborn to promote extension of muscles. C. Keep the newborn in a well-lit nursery. D. Use fingertips when calming the newborn.

Correct Answer is A

Explanation

A. Cluster the newborn's care activities: Clustering care activities allows the newborn to have periods of rest between interventions, promoting less stress and supporting physiological stability. This approach also mimics natural sleep-wake cycles, essential for a preterm newborn's development.

B. Position the newborn to promote extension of muscles: Positioning to promote muscle extension is not ideal for preterm infants. Preterm infants benefit from positioning that mimics the fetal position, which encourages flexion rather than extension of muscles, providing comfort and promoting development.

C. Keep the newborn in a well-lit nursery: Preterm infants are sensitive to bright lights, and exposure to a well-lit environment can cause stress and disrupt sleep. It’s crucial to maintain a dimly lit environment to mimic the womb, promote rest, and reduce overstimulation.

D. Use fingertips when calming the newborn: When calming a preterm newborn, gentle touch is more appropriate. Using the fingertips or palm of the hand provides a more soothing, less overstimulating approach to handling the baby.

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Which of the following components are used to calculate the Apgar score for a newborn? (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who is postpartum and has a new prescription for an injection of Rh, (D) immunoglobulin. Which of the following should be included in the teaching?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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Which of the following components are used to calculate the Apgar score for a newborn?
(Select All that Apply.)