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.

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Correct Answer is B

Explanation

Choice A reason:
The deltoid muscle, while commonly used for IM injections in older children and adults, is not the preferred site for newborns due to their underdeveloped muscle mass in this area. Administering an injection in the deltoid could increase the risk of injury to the surrounding nerves and tissues in newborns.

Choice B reason:
The vastus lateralis muscle is the recommended site for IM injections in newborns. It is the preferred location because it is the largest muscle in the thigh and has sufficient mass to absorb the medication effectively. This muscle is located on the anterolateral aspect of the thigh and is considered the safest site with the least risk of damaging blood vessels, nerves, or bone.

Choice C reason:
The dorsogluteal muscle, located in the buttocks, was once a common site for IM injections. However, it is no longer recommended due to the high risk of injury to the sciatic nerve and significant blood vessels in the area. Additionally, the fat content in the buttocks can affect the absorption of the medication.

Choice D reason:
The ventrogluteal muscle, also located in the hip area, is another site for IM injections but is more suitable for older children and adults. For newborns, the vastus lateralis remains the preferred site due to easier access and less risk of complications.

A. Prepare to administer a prescribed oxytocic preparation. B. Assess the bladder for distention. C. Massage the client's fundus. D. Assess the client's blood pressure.

Correct Answer is C

Explanation

Choice A reason:
Administering a prescribed oxytocic preparation is an important step in managing postpartum hemorrhage, as it helps to contract the uterus and reduce bleeding. However, it is not the first action a nurse should take when a client has saturated a perineal pad within 10 minutes postpartum.

Choice B reason:
Assessing the bladder for distention is also important because a full bladder can impede the contraction of the uterus and lead to increased bleeding. However, this is not the immediate action to take in the event of excessive postpartum bleeding.

Choice C reason:
Massaging the client's fundus is the first action the nurse should take. A boggy uterus, which is soft and not well contracted, can lead to excessive bleeding. Fundal massage stimulates the uterus to contract and can quickly reduce blood loss.

Choice D reason:
Assessing the client's blood pressure is vital to determine the client's hemodynamic status, but it is not the first action to take. The priority is to address the cause of the bleeding and stabilize the client.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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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?