Normal Variations and Abnormal Findings

Normal Variations and Abnormal Findings ( 5 Questions)

A nurse is caring for a newborn who has a temperature of 36.1°C (97°F), heart rate of 140/min, respiratory rate of 50/min, muscle tone of 1, and reflex irritability of 1.

What is the newborn’s APGAR score at 1 minute?



Correct Answer: B

5. The APGAR score is a method of assessing the health of a newborn based on five criteria: appearance (skin color), pulse (heart rate), grimace (reflex irritability), activity (muscle tone), and respiration (breathing rate and effort).

Each criterion is scored from 0 to 2, with a total score ranging from 0 to 10.

A higher score indicates a better condition of the newborn.

The newborn in the question has a score of 1 for appearance (pale or blue extremities), 1 for pulse (heart rate below 160/min), 1 for grimace (minimal response to stimulation), 1 for activity (some flexion of extremities), and 1 for respiration (slow or irregular breathing).

The sum of these scores is 5.

Choice A is wrong because a score of 4 would mean that the newborn has a score of 0 for one of the criteria, which is not the case.

Choice C is wrong because a score of 6 would mean that the newborn has a score of 2 for one of the criteria, which is not the case.

Choice D is wrong because a score of 7 would mean that the newborn has a score of 2 for two of the criteria, which is not the case.

The normal ranges for each criterion are:

• Appearance: 0 (blue or pale all over), 1 (pink body but blue extremities), or 2 (pink all over).

• Pulse: 0 (absent), 1 (below 100/min), or 2 (above 100/min).

• Grimace: 0 (no response to stimulation), 1 (grimace or weak cry), or 2 (vigorous cry).

• Activity: 0 (limp or flaccid), 1 (some flexion of extremities), or 2 (active movement).

• Respiration: 0 (absent), 1 (slow or irregular), or 2 (good and regular).




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