Newborn Assessment > Maternal & Newborn
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APGAR Score (0-10)
Total Questions : 4
Showing 4 questions, Sign in for moreA nurse is assessing a newborn at 1 minute after birth.
The newborn has a heart rate of 150 bpm, a strong cry, well-flexed muscle tone, pink body with blue hands and feet, and grimaces when suctioned.
What is the newborn’s APGAR score?
Explanation
The newborn’s APGAR score is 8.The APGAR score is a test given to newborns soon after birth to assess their health based on five categories: appearance, pulse, grimace, activity, and respiration.Each category is scored from 0 to 2 points, with a total score of 10 being the best.A score of 7 to 10 is normal and indicates that the newborn is in good health.
Choice A is wrong because a score of 7 would mean that the newborn has one less point in one of the categories.For example, if the newborn had a heart rate of less than 100 beats per minute, that would be 1 point instead of 2 points for pulse.
Choice C is wrong because a score of 9 would mean that the newborn has perfect scores in all categories except appearance.Most babies have blue hands or feet immediately after birth, which gives them 1 point instead of 2 points for appearance.
Choice D is wrong because a score of 10 is very rare and would mean that the newborn has perfect scores in all categories.This is unlikely because most babies have blue hands or feet immediately after birth, which gives them 1 point instead of 2 points for appearance.
A nurse is teaching a group of expectant parents about the APGAR score.
Which of the following statements by one of the parents indicates an understanding of the teaching?
Explanation
“The APGAR score helps to identify any problems that require immediate attention.” The APGAR score is a test given to newborns soon after birth to assess their health and well-being.
It is based on five categories: appearance, pulse, grimace, activity, and respiration.
Each category is scored from 0 to 2 points, with a total score of 10 being the best.The test is usually done at one and five minutes after birth, and sometimes again at 10 minutes if the score is low.
Choice A is wrong because the APGAR score does not measure blood pressure, temperature, or pulse oximetry.These are separate tests that may be done on newborns if needed.
Choice B is wrong because the APGAR score is done before and after the delivery of the baby, not the placenta.The placenta is delivered after the baby and does not affect the baby’s health.
Choice D is wrong because the APGAR score is based on a scale of 0 to 10, not 0 to 5.A score of 7 or above is considered normal and reassuring, while a score of 4 to 6 is moderately abnormal and a score of 0 to 3 is concerning.
A nurse is reviewing the chart of a newborn who has an APGAR score of 2 at 1 minute after birth and an APGAR score of 6 at 5 minutes after birth.
Which of the following factors could have contributed to these scores? (Select all that apply.)
Explanation
The factors that could have contributed to these scores are A, D, and E. These are:
A. The mother received magnesium sulfate during labor.This statement is correct because magnesium sulfate can cause neonatal depression and lower the APGAR score.
D. The newborn had meconium-stained amniotic fluid.This statement is correct because meconium aspiration can cause respiratory distress and lower the APGAR score.
E. The mother had preeclampsia.This statement is correct because preeclampsia can cause placental insufficiency and fetal hypoxia, which can lower the APGAR score.
B. The newborn was delivered by cesarean section.This statement is wrong because cesarean delivery does not affect the APGAR score unless there are complications.
C. The mother had gestational diabetes mellitus.This statement is wrong because gestational diabetes mellitus does not affect the APGAR score unless it causes macrosomia or hypoglycemia in the newborn.
A nurse is preparing to assess the APGAR score of a newborn at 1 minute after birth.
Which of the following actions should the nurse take?
Explanation
The correct answer is choice B. Observe the respiratory effort by looking at the chest movements.This is one of the five categories that the Apgar score uses to assess the newborn’s condition at one and five minutes after birth.The other categories are activity/muscle tone, pulse/heart rate, grimace/response to stimulation, and appearance/color.Each category receives a score of 0 to 2 points, with a maximum total score of 10.
Choice A is wrong because counting the heart rate for a full minute using a stethoscope is not necessary.The pulse can be assessed by feeling the umbilical cord or placing a hand over the chest.
Choice C is wrong because assessing the muscle tone by placing the newborn in a prone position is not recommended.The muscle tone can be evaluated by observing how much the baby is moving around and how flexed their limbs are.
Choice D is wrong because evaluating the reflex irritability by flicking the sole of the foot is not the best way to stimulate the baby.The reflex irritability can be tested by suctioning the baby’s nose or rubbing their back.
The normal ranges for each category are as follows:
• Activity/muscle tone: 0 points for limp or floppy, 1 point for limbs flexed, 2 points for active movement
• Pulse/heart rate: 0 points for absent, 1 point for less than 100 beats per minute, 2 points for greater than 100 beats per minute
• Grimace/response to stimulation: 0 points for
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