A nurse is assisting in the care of a newborn immediately after birth. At 5 min after birth, the newborn has acrocyanosis, flexed extremities, a grimace when suctioned, a heart rate of 130/min, and a lusty cry with tactile stimulation. What should the nurse document as the newborn's 5-min Apgar score?
7
8
9
10.
The Correct Answer is A
Step 1 is assessing heart rate. A heart rate of 130/min earns 2 points since a rate above 100/min is optimal.
Step 2 is assessing respiratory effort. A lusty cry earns 2 points as strong crying indicates good respiratory function.
Step 3 is assessing muscle tone. Flexed extremities earn 1 point since full active movement would score 2.
Step 4 is assessing reflex irritability. Grimace when suctioned earns 1 point as a vigorous response (cough, sneeze) would score 2.
Step 5 is assessing color. Acrocyanosis earns 1 point since a fully pink body scores 2.
Final answer: 7
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
The umbilical cord typically contains two arteries and one vein. Arteries carry oxygen-depleted blood and waste products from the fetus to the placenta for removal, while the vein carries oxygenated blood and nutrients from the placenta to the fetus. This arrangement is essential for maintaining proper fetal circulation during pregnancy.
Choice B rationale:
This choice is incorrect because the umbilical cord usually contains two arteries and one vein, not just one artery and one vein. Having only one artery could indicate a potential vascular abnormality or congenital issue that may require further investigation or medical attention.
Choice C rationale:
This is the correct answer. The umbilical cord usually contains two arteries and one vein. The presence of two arteries allows for the efficient removal of waste products and carbon dioxide from the fetus, while the single vein delivers essential nutrients and oxygen to support the baby's growth and development.
Choice D rationale:
This choice is incorrect as it states two veins and one artery, which is not the typical configuration of blood vessels in the umbilical cord. Having two veins and one artery would disrupt fetal circulation and hinder proper nutrient and waste exchange between the fetus and the placenta.
Correct Answer is B
Explanation
Choice A rationale:
Choice A, fetal head compression, is not the correct answer in this case. Fetal head compression can cause early decelerations in the FHR, not variable decelerations. Early decelerations are often a result of the fetal head being compressed during contractions and are considered benign and expected during labor.
Choice B rationale:
The correct answer is choice B, which is umbilical cord compression. Variable decelerations of the fetal heart rate (FHR) can occur during labor due to various rationales, and umbilical cord compression is one of the common causes. When the umbilical cord gets compressed, it can briefly reduce or restrict the blood flow and oxygen supply to the fetus, leading to temporary decelerations in the FHR.
Choice C rationale:
Choice C, maternal fever, is also not the correct answer for variable decelerations in FHR. Maternal fever can be a sign of infection, and it may lead to other fetal heart rate abnormalities, such as tachycardia (an increased heart rate), but it is not specifically associated with variable decelerations.
Choice D rationale:
Choice D, polyhydramnios, is not the cause of variable decelerations in this scenario. Polyhydramnios refers to an excessive accumulation of amniotic fluid around the fetus. While it can have implications for pregnancy, it is not directly linked to variable decelerations of the FHR.
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