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 D
Explanation
A. “Do you think you could keep him in the nursery for the next feeding so I can get some sleep?”: This statement does not necessarily indicate an inhibition of parental attachment. The new mother may just be tired and need some rest, which is quite normal after childbirth.
B. “He’s got my husband’s nose, that’s for sure”: This statement indicates a positive parental attachment as the mother is identifying familial traits in her newborn.
C. “I don’t need a baby bath demonstration. I know how to do it”: This statement suggests that the mother is confident in her ability to care for her baby, which is a positive sign of parental attachment.
D. “I wish he had more hair. I will keep a hat on his head until he grows some”: This is the correct answer. This statement could indicate an inhibition of parental attachment as the mother seems to be focusing on a perceived imperfection in her baby rather than accepting and loving her baby as they are. It’s important to note that this is just one potential sign and should be considered in the context of other behaviors and interactions between the mother and baby.
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