A nurse is caring for a newborn and calculating the Apgar score. At 1 min after delivery, the following findings are noted: heart rate of 110/min; slow, weak cry, some flexion of extremities; grimace in response to suctioning of the nares; body pink in color with blue extremities.
Calculate the newborn's Apgar score.
The Correct Answer is ["6"]
The Apgar score is 6.
It is based on 5 signs evaluated at 1 and 5 minutes after delivery that indicate the physiologic state of the neonate: heart rate over 100 = 2; slow, weak cry = 1; some flexion of extremities = 1; grimace in response to suctioning of the nares = 1; body pink in color with blue extremities = 1.
Total score= 6
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Potential condition
Correct Answer: B. Meningocele
Rationale: Based on the provided physical examination details, the newborn is most likely experiencing a meningocele, which is indicated by the presence of a sac in the lumbar area. This condition is a type of neural tube defect where a sac of fluid comes through an opening in the baby's back. However, the absence of other neurological symptoms and the intactreflexes suggest that the condition has not severely affected the newborn's neurological functions.
Actions to Take (2)
Correct Answers: C, E
The two actions the nurse should take to address this condition include: applying a non-adhering sterile saline moist compress to the sac to prevent it from drying and to protect it from trauma, and educating the guardians about the condition, its implications, and the potential need for surgical intervention to repair the defect.
Parameters to monitor
Correct Answer: A, C
Rationale: The two parameters the nurse should monitor to assess the newborn's progress are the head circumference and serial head ultrasounds. Monitoring head circumference is crucial as an increase may indicate hydrocephalus, which can be associated with meningocele. Serial head ultrasounds are necessary to assess for any changes in the brain structure or development of hydrocephalus. These measures will help ensure that any complications are identified and managed promptly.
Correct Answer is C
Explanation
Rationale:
A. While covering the cord with a sterile, moist saline dressing is important, it is not the first priority when the umbilical cord is prolapsed.
B. While preparing for an immediate birth may become necessary, the first action should be to relieve pressure on the cord to prevent cord compression and compromise to fetal circulation.
C. This is the priority action to prevent cord compression and maintain fetal oxygenation.
D. Placing the client in the knee-chest position can help relieve pressure on the cord, but the nurse's immediate action should be to manually support the cord while awaiting further
instructions from the healthcare provider.
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