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. Inform the client the anesthetic effect will last for approximately 6 hours: This is not the priority nursing action following an amniotomy. Anesthesia may not even be used during an amniotomy, and the duration of its effect varies depending on the type and individual response.
B. Obtain a 30 min electronic fetal monitoring (EFM) strip prior to induction: This is the correct choice. It’s important to assess the baseline fetal heart rate and any existing decelerations or accelerations before the procedure. This can help identify any potential distress the fetus may experience during the procedure.
C. Administer a 500 mL bolus of 5% dextrose in water prior to induction: While hydration is important during labor, it is not the priority nursing action following an amniotomy. The need for a fluid bolus would be based on the client’s individual condition and provider’s orders.
D. Have the client stand at the bedside with her arms at her side: This is not the priority nursing action following an amniotomy. The client’s position would be determined by her comfort and the stage of labor, but it is not the first action a nurse should take after an amniotomy.
Correct Answer is D
Explanation
A. Headache for 30 min: While a headache can be a side effect of magnesium sulfate, it is not typically a critical concern that needs to be reported immediately. However, persistent or severe headaches should be reported.
B. Fetal heart rate 158/min: This is within the normal range for a fetal heart rate (110-160 beats per minute), so it would not typically need to be reported.
C. Respirations 16/min: This is within the normal range for adult respiratory rate (12-20 breaths per minute), so it would not typically need to be reported.
D. Urinary output 40 mL in 2 hours: This is the correct answer. A urinary output of less than 30 mL/hr. may indicate renal insufficiency, which can be a serious side effect of magnesium sulfate therapy. This should be reported to the provider immediately.
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