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","C","D"]
Explanation
Choice a) Reason: History of migraines
Women with a history of migraines may experience an improvement or worsening of their migraine symptoms during pregnancy. Hyperemesis gravidarum, a condition characterized by severe nausea and vomiting, can be associated with migraines due to hormonal changes, stress, or dehydration that pregnancy may exacerbate.
Choice b) Reason: History of gestational hypertension
Gestational hypertension typically develops after 20 weeks of gestation, so it would not be expected in a client at 8 weeks of gestation. Additionally, there is no direct correlation between gestational hypertension and hyperemesis gravidarum.
Choice c) Reason: Twin gestations
Twin or multiple gestations can increase the likelihood of hyperemesis gravidarum due to higher levels of hCG (human chorionic gonadotropin) and other pregnancy-related hormones. These elevated hormone levels are associated with more severe nausea and vomiting.
Choice d) Reason: Nulliparous
Nulliparity (having never given birth) is not directly associated with an increased risk of hyperemesis gravidarum. However, first-time pregnancies can be unpredictable, and the condition can occur regardless of parity.
Choice e) Reason: Oligohydramnios
Oligohydramnios refers to a decreased amount of amniotic fluid and is not typically associated with hyperemesis gravidarum. It is more commonly related to conditions affecting the placenta or fetal kidneys.
Correct Answer is D
Explanation
Choice A reason:
Nausea can be a common side effect of many medications and does not necessarily indicate toxicity. While it can be uncomfortable for the patient, nausea alone, without other symptoms, is not typically a sign of magnesium sulfate toxicity.
Choice B reason:
Drowsiness is another side effect that can occur with various medications and medical conditions. It may be a symptom of magnesium sulfate toxicity, especially if it is severe or combined with other symptoms, but on its own, it is not a definitive indicator of toxicity.
Choice C reason:
Facial flushing can be a reaction to medication, including magnesium sulfate, and may occur even at therapeutic levels. It is not usually a sign of toxicity unless accompanied by more serious symptoms.
Choice D reason:
Respiratory depression is a serious and potentially life-threatening condition that can indicate magnesium sulfate toxicity. It is characterized by a decrease in the ability to breathe and a drop in oxygen levels. This is a critical finding that requires immediate medical attention and intervention.
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