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 ["A","B","C"]
Explanation
A. Amniotic fluid volume: This is correct. The biophysical profile evaluates the volume of amniotic fluid, which can provide information about the health of the fetus and the placenta.
B. Fetal motion: This is correct. The biophysical profile assesses fetal motion, including gross body movements and fetal tone (flexion and extension of extremities).
C. Fetal breathing: This is correct. The biophysical profile includes an assessment of fetal breathing movements, which are a sign of fetal well-being.
D. Fetal gender: This is not correct. The biophysical profile does not evaluate the gender of the fetus. The gender can be determined through other ultrasound examinations, but it is not part of the biophysical profile.
E. Fetal neck translucency: This is not correct. Fetal neck translucency is assessed during a specific type of ultrasound examination performed in the first trimester to screen for chromosomal abnormalities, not during a biophysical profile. The biophysical profile is typically performed in the third trimester to assess fetal well-being.
Correct Answer is C
Explanation
A. Accelerations: These are usually a good sign and indicate that the fetus is well-oxygenated.
B. Late decelerations: These are a sign of uteroplacental insufficiency, not a problem with the umbilical cord. They occur when the blood supply to the placenta is reduced during contractions, leading to a decrease in oxygen supply to the fetus.
C. Variable decelerations: This is the correct choice. Variable decelerations can be an indication of umbilical cord compression. They are called “variable” because they can occur at any time during the contraction cycle and can vary in depth and duration.
D. Early decelerations: These are usually benign and are often associated with fetal head compression during contractions, not a problem with the umbilical cord.
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