A nurse is caring for a newborn and calculating the Apgar score at 1 minute after delivery, the following findings are noted:
- Slow, weak cry
- Some flexion of extremities
- Grimace in response to suctioning at the nares
- Body pink in color
- Blue extremities
Calculate the newborn's Apgar score.
The Correct Answer is ["5"]
The Apgar score is calculated based on five components: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Each component is scored from 0 to 2, with 2 being the best score. Here’s how this newborn’s Apgar score adds up:
Heart Rate: A slow, weak cry suggests a heart rate less than 100 beats per minute, which scores a 1.
Respiratory Effort: A slow, weak cry also suggests that the baby’s respiratory effort is slow or irregular, which scores a 1.
Muscle Tone: Some flexion of extremities indicates some muscle tone, but not completely normal, which scores a 1.
Reflex Irritability: A grimace in response to suctioning at the nares indicates some reflex irritability, which scores a 1.
Color: A body pink in color with blue extremities indicates that the baby is not completely pink, which scores a 1.
Adding these scores together, the newborn’s Apgar score at 1 minute after delivery is 5 units.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Accidental lacerations: While accidental lacerations can occur during a cesarean delivery, they are not common and are not the priority assessment.
B. Respiratory distress: This is the correct answer. Immediately after birth, the newborn’s ability to establish effective respirations is critical. Any signs of respiratory distress should be addressed immediately to ensure adequate oxygenation.
C. Acrocyanosis: Acrocyanosis, or blueness of the hands and feet, is common in newborns and is not typically a cause for immediate concern.
D. Hypothermia: Maintaining the newborn’s body temperature is important, but it is not the priority over ensuring the newborn is breathing effectively.
Correct Answer is B
Explanation
A. Nonstress test is reactive: A reactive nonstress test indicates that the fetus is getting enough oxygen, which is a good sign, but it does not specifically indicate lung maturity.
B. Lecithin-sphingomyelin (L/S) ratio of 2:1: This is the correct answer. An L/S ratio of 2:1 or greater is a good indicator of fetal lung maturity. Lecithin and sphingomyelin are both types of phospholipids that make up surfactant, a substance that helps the lungs expand and prevents them from collapsing. As the fetal lungs mature, the amount of lecithin increases while the amount of sphingomyelin stays the same, leading to an increased L/S ratio.
C. Phosphatidylglycerol (PC) absent: The presence of phosphatidylglycerol (not its absence) in amniotic fluid is another indicator of lung maturity. It usually appears in significant amounts about the 35th week of gestation.
D. Biophysical profile score of 8: A biophysical profile score assesses the health of the fetus by looking at fetal heart rate, muscle tone, movement, breathing, and the amount of amniotic fluid. While a score of 8 out of 10 is generally considered good, it does not specifically indicate lung maturity.
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