A nurse observes 5 minutes after delivery that a newborn has a pink trunk and head, bluish hands and feet, and a heart rate of 130/min. He has flexed extremities and a weak, slow cry. The nurse should document what Apgar score for this infant?
5
6
7
8
9
The Correct Answer is B
Choice A Reason:
The Apgar score is a quick test performed on a newborn at 1 and 5 minutes after birth. The 5 criteria assessed are Appearance (skin color), Pulse (heart rate), Grimace response (reflexes), Activity (muscle tone), and Respiration (breathing effort). Each criterion is scored on a scale of 0 to 2, with 2 being the best score. The total score is calculated by adding the scores of all five criteria, with a maximum possible score of 10.
For this newborn:
• Appearance: The newborn has a pink trunk and head but bluish hands and feet, which scores 1 point12.
• Pulse: The heart rate is 130/min, which scores 2 points1.
• Grimace: The newborn has a weak, slow cry, which scores 1 point3.
• Activity: The newborn has flexed extremities, which scores 1 point3.
• Respiration: The newborn has a weak, slow cry, which scores 1 point3.
Adding these scores: 1 (Appearance) + 2 (Pulse) + 1 (Grimace) + 1 (Activity) + 1 (Respiration) = 6.
Choice B Reason:
This choice is correct. As explained above, the total Apgar score for this newborn is 6. The breakdown of the scores is as follows:
• Appearance: 1 point for pink trunk and head, bluish hands and feet.
• Pulse: 2 points for a heart rate of 130/min.
• Grimace: 1 point for a weak, slow cry.
• Activity: 1 point for flexed extremities.
• Respiration: 1 point for a weak, slow cry.
Choice C Reason:
This choice is incorrect. A score of 7 would require higher scores in one or more of the criteria. For example, if the newborn had a strong cry (2 points for Grimace and Respiration) or if the entire body was pink (2 points for Appearance), the total score would be higher.
Choice D Reason:
This choice is incorrect. A score of 8 would require even higher scores in the criteria. For instance, if the newborn had a strong cry and the entire body was pink, the total score would be 8 or higher.
Choice E Reason:
This choice is incorrect. A score of 9 would require almost perfect scores in all criteria, which is not the case for this newborn. The newborn’s weak, slow cry and bluish hands and feet lower the total score.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
A large amount of vaginal bleeding is not typically associated with an ectopic pregnancy. While some vaginal bleeding can occur, it is usually light and not the primary symptom. Heavy bleeding is more commonly associated with other complications such as miscarriage or placental issues.
Choice B reason:
Uterine enlargement greater than expected for gestational age is not a characteristic of ectopic pregnancy. In fact, the uterus may not enlarge significantly because the pregnancy is occurring outside the uterine cavity. This symptom is more indicative of conditions like molar pregnancy.
Choice C reason:
Severe nausea and vomiting are common symptoms of a normal pregnancy due to hormonal changes but are not specific to ectopic pregnancy. While some women with ectopic pregnancies may experience nausea and vomiting, these symptoms alone are not diagnostic.
Choice D reason:
Unilateral, cramp-like abdominal pain is a hallmark symptom of ectopic pregnancy. This pain typically occurs on one side of the abdomen, corresponding to the location of the ectopic implantation, usually in a fallopian tube. The pain can become severe and is often accompanied by light vaginal bleeding. If the fallopian tube ruptures, the pain can become intense and may be accompanied by signs of internal bleeding, such as dizziness, shoulder pain, and shock.
Correct Answer is A
Explanation
Choice A reason:
The indirect Coombs test is used to detect Rh-positive antibodies in the mother’s blood. This test is crucial for Rh-negative mothers who have given birth to Rh-positive infants. It helps determine if the mother has been sensitized to Rh-positive blood and has developed antibodies against it. If these antibodies are present, they can cross the placenta in future pregnancies and attack the red blood cells of an Rh-positive fetus, leading to hemolytic disease of the newborn.
Choice B reason:
The statement “It determines the presence of maternal antibodies in the newborn’s blood” is incorrect. The indirect Coombs test is performed on the mother’s blood, not the newborn’s. It screens for antibodies that could potentially harm the fetus in future pregnancies. The direct Coombs test, on the other hand, is used to detect antibodies that are already attached to the newborn’s red blood cells.
Choice C reason:
The statement “It detects Rh-negative antibodies in the newborn’s blood” is incorrect. The indirect Coombs test does not detect Rh-negative antibodies in the newborn’s blood. Instead, it identifies antibodies in the mother’s blood that could react against Rh-positive red blood cells. This test helps in assessing the risk of hemolytic disease in future pregnancies.
Choice D reason:
The statement “It determines if kernicterus will occur in the newborn” is incorrect. Kernicterus is a severe form of jaundice caused by high levels of bilirubin in the blood. While the Coombs test can help identify hemolytic disease, which can lead to jaundice, it does not directly determine the risk of kernicterus. The primary purpose of the indirect Coombs test is to detect antibodies that could cause hemolytic disease in future pregnancies.
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