A nurse observes that a newborn has a pink trunk and head, bluish hands and feet, and flexed extremities 5 min after delivery. He has a weak and
slow cry, a heart rate of 130/min, and cries in response to suctioning. The nurse should document what Apgar score for this infant?
The Correct Answer is ["8"]
In the scenario provided, the Apgar score is calculated as follows:
- Appearance (skin color): The newborn has a pink trunk and head with bluish hands and feet, which scores 1 point.
- Pulse (heart rate): The heart rate is 130/min, which is above 100/min, so this scores 2 points.
- Grimace response (reflex irritability): The newborn cries in response to suctioning, which scores 2 points.
- Activity (muscle tone): The newborn has flexed extremities, which scores 2 points.
- Respiration (breathing effort): The cry is weak and slow, which scores 1 point.
Adding these up gives us a total Apgar score of 8 out of a possible 10 points.
Appearance (skin color): Normally, a score of 2 is given if the entire body is pink, 1 for pink body but blue extremities, and 0 if the whole body is pale or blue. The newborn's pink trunk and head with bluish hands and feet warrant a score of 1.
Pulse (heart rate): A score of 2 is given for a heart rate above 100/min, 1 for below 100/min, and 0 if there is no heartbeat. The newborn's heart rate of 130/min earns a score of 2.
Grimace response (reflex irritability): A score of 2 is given for a sneeze, cough, or vigorous cry, 1 for a grimace or feeble cry upon stimulation, and 0 for no response. The newborn's crying in response to suctioning gets a score of 2.
Activity (muscle tone): A score of 2 is given for active motion, 1 for some muscle tone and flexion of extremities, and 0 for limpness. The newborn's flexed extremities give a score of 2.
Respiration (breathing effort): A score of 2 is given for a good, strong cry, 1 for slow or irregular breathing, and 0 for no breathing. The newborn's weak and slow cry results in a score of 1.
The Apgar score helps the healthcare team decide if the newborn needs immediate medical care. A score of 7-10 is generally normal, 4-6 fairly low, and 3 and below critically low. An Apgar score of 8 indicates that the newborn is in good health but may need some medical attention, likely due to the weak and slow cry.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Tipping the nipple to allow air as the baby sucks can lead to the baby ingesting air, which may cause discomfort and increase the risk of colic. Proper bottle feeding technique involves tilting the bottle to fill the nipple with milk, thus preventing the baby from swallowing air.
Choice B reason:
Keeping the baby's head elevated during feeding is recommended to prevent milk from flowing too fast and to reduce the risk of ear infections and choking. It also aids in proper digestion and helps prevent reflux.
Choice C reason:
Allowing the baby to burp several times during each feeding is important to release any air swallowed during feeding. This can help prevent discomfort, gas, and spit-up. Burping can be done by gently patting the baby's back in different positions such as over the shoulder, sitting up, or lying across the lap.
Choice D reason:
Expecting soft, formed yellow stools is appropriate for a newborn, especially if breastfed, as their stools tend to be soft and a mustard yellow color. The frequency and consistency of stools can vary, but they generally reflect the baby's diet and are an indicator of good health.
Correct Answer is B
Explanation
Choice A reason:
Applying petroleum jelly to the umbilical cord stump is not recommended. The goal is to keep the stump dry to encourage the healing process. Petroleum jelly is a moisture barrier and could potentially keep the area too moist, which may delay the drying and falling off of the stump.
Choice B reason:
Giving sponge baths until the cord stump falls off is the correct practice. It is important to keep the stump dry, so sponge baths are preferred over tub baths during this time. This helps prevent the stump from staying wet, which can lead to infection or delayed healing.
Choice C reason:
It is not advised to cover the cord with the diaper. Instead, the diaper should be folded down away from the stump or use diapers with a special cut-out to keep the stump exposed to air. This helps the stump to dry and fall off more quickly.
Choice D reason:
Washing the cord daily with mild soap and water is not necessary and could be counterproductive. The stump should be kept dry, and if it gets dirty, it can be cleaned gently with a soft, damp cloth and then dried thoroughly. Regular bathing can introduce moisture, which may increase the risk of infection.
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