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?

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A Reason:
Peanut butter should be eliminated from the diet of a pregnant client with PKU. It is a high-protein food that contains phenylalanine, an amino acid that individuals with PKU cannot metabolize properly¹. The accumulation of phenylalanine can lead to serious health issues for both the mother and the developing fetus, including the risk of intellectual disability in the child.

Choice B Reason:
Potatoes are generally safe for individuals with PKU to consume. They are not high in protein and thus do not contain large amounts of phenylalanine. However, portion sizes and overall dietary balance should be monitored by a healthcare professional to ensure proper nutrition.

Choice C Reason:
Apple juice is also safe for individuals with PKU. It does not contain protein and therefore is not a significant source of phenylalanine. It can be included in the diet as part of the fluid intake.

Choice D Reason:
Broccoli is a low-protein vegetable and is typically allowed in the diets of individuals with PKU. It contains some phenylalanine, but in much lower amounts compared to high-protein foods. As with all foods, it should be consumed in moderation according to dietary guidelines provided by a healthcare professional.

A. "Exposure to rubella will suppress the newborn's immune response." B. "The child might develop encephalitis, a complication of rubella." C. "The newborn is at risk for developing a TORCH infection." D. "The newborn might be actively shedding the virus."

Correct Answer is D

Explanation

Choice A reason:
The statement that exposure to rubella will suppress the newborn's immune response is not entirely accurate. While rubella can affect the immune system, the primary concern with newborns is the risk of congenital rubella syndrome (CRS), which can cause a variety of health problems, including developmental delays and organ damage. The newborn's immune system is not fully developed, and while rubella can lead to immunosuppression, the main reason for isolation is to prevent the spread of the virus.

Choice B reason:
Encephalitis is an inflammation of the brain that can be caused by various infections, including rubella. However, it is not the most common complication associated with congenital rubella. The primary concerns with CRS are hearing loss, heart defects, and ocular issues, such as cataracts. While encephalitis is a serious condition, the immediate reason for isolation is to prevent the transmission of the virus, not specifically because of the risk of encephalitis.

Choice C reason:
TORCH infections refer to a group of infections that can cause serious health problems in newborns. The acronym stands for Toxoplasmosis, Other (such as syphilis), Rubella, Cytomegalovirus, and Herpes simplex virus. While it is true that the newborn is at risk for developing CRS, which is part of the TORCH group, the term "TORCH infection" is a broader category and does not specifically explain why the newborn is being isolated.

Choice D reason:
The most appropriate response is that the newborn might be actively shedding the virus. Newborns with congenital rubella can shed the virus for an extended period after birth. This means they can potentially spread the virus to others, which is why isolation is necessary. Isolation helps protect other newborns, pregnant women, and immunocompromised individuals from contracting rubella, which can have serious consequences.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who is pregnant and has phenylketonuria (PKU). Which of the following foods should the nurse instruct the client to eliminate from her diet?

Correct Answer is A

Explanation

A nurse is caring for a client who has rubella at the time of delivery and asks why her newborn is being placed in isolation. Which of the following responses by the nurse is appropriate?

Correct Answer is D

Explanation

A nurse is preparing to administer liquid mycostatin 600,000 units PO TID. Available is mycostatin 100,000 units/mL. How many m. should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is observing a new mother bathing her newborn son for the first time. For which of the following actions should the nurse intervene?

A nurse is caring for a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client?

A nurse is caring for a client who is 2 hours postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

A nurse is preparing to administer vitamin K by IM injection to a newborn. The nurse should administer the medication into which of the following muscles?

A nurse in a clinic is assessing a client who is at 8 weeks of gestation and has hyperemesis gravidarum. Which of the following findings should the nurse expect? (Select all that apply)

A nurse is teaching a client who is at 23 weeks of gestation and will return to the facility in 2 days for an amniocentesis. Which of the following instructions should the nurse give the client?

A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?

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?