What Apgar score should a nurse document for a newborn with a pink trunk and head, bluish hands and feet, flexed extremities 5 min after delivery, a weak and slow cry, a heart rate of 130/min, and cries in response to suctioning?
7
8
9
10
The Correct Answer is B
Choice A rationale
An Apgar score of 7 is considered fairly low and would typically be associated with a newborn who has more significant health concerns.
Choice B rationale
An Apgar score of 8 is considered to be within the normal range. This score would be consistent with a newborn who has a pink trunk and head, bluish hands and feet, flexed extremities, a weak and slow cry, a heart rate of 130/min, and cries in response to suctioning.
Choice C rationale
An Apgar score of 9 is considered to be within the normal range. However, given the newborn’s weak and slow cry, an Apgar score of 9 would be less likely.
Choice D rationale
An Apgar score of 10 is very unusual, as almost all newborns lose 1 point for blue hands and feet, which is normal for after birth.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While accidental lacerations can occur during a cesarean delivery, they are not typically the primary concern immediately after delivery.
Choice B rationale
Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns and is not typically a priority concern immediately after delivery.
Choice C rationale
Respiratory distress is a priority concern in a newborn after a cesarean delivery. Newborns delivered by cesarean may have transient tachypnea of the newborn (TTN), a condition characterized by rapid breathing during the first few hours of life.
Choice D rationale
While hypothermia is a concern in newborns, it is not typically the immediate priority following a cesarean delivery.
Correct Answer is D
Explanation
The correct answer is Choice D
Choice A rationale: Notifying the provider is important but not the first priority in this situation. The maternal hypotension (BP 92/54 mm Hg) and elevated maternal heart rate (128/min) suggest decreased perfusion, which can compromise uteroplacental blood flow. Immediate intervention is required before notifying the provider, especially if positioning can restore circulation and fetal oxygenation. Waiting to call without correcting the underlying cause may result in fetal distress or worsening maternal status.
Choice B rationale: While uncontrolled pain may contribute to elevated maternal heart rate, the hypotension and tachycardia suggest a more urgent hemodynamic imbalance. Pain management may become appropriate after stabilizing maternal circulation. Focusing on pain relief first delays essential interventions to improve perfusion, risking fetal compromise due to inadequate uteroplacental oxygen delivery. The fetal heart rate of 130/min is reassuring, but maternal circulation must be prioritized to sustain it.
Choice C rationale: A full bladder can contribute to uterine displacement, but there is no indication in the scenario that bladder distention is an issue. Voiding may be done later but does not address the immediate concern of maternal hypotension and compensatory tachycardia. Uteroplacental perfusion depends heavily on maternal blood pressure, and bladder status has secondary importance in the acute phase of circulatory compromise.
Choice D rationale: Elevating one hip improves venous return and cardiac output by relieving pressure on the inferior vena cava, which is compressed by the gravid uterus in the supine position. This correction reduces hypotension and restores uteroplacental perfusion. The maneuver is a first-line response for maternal hypotension in labor, helping stabilize both mother and fetus quickly. Fetal oxygen delivery depends on adequate maternal perfusion, which this position supports.
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