Apgar Scoring
A nurse is assessing a newborn who is 5 min old. The newborn has a slow & weak cry, flaccid tone, pale color, grimace, & a heart rate of 120/min. Which of the following Apgar scores should the nurse assign the newborn? -2 -6 -4 -3
-4 Rationale: The nurse should score the newborn 2 for heart rate of 120/min, 1 for rest effort (slow/weak cry), 0 for muscle tone (flaccid), 1 for reflex irritability (grimace), & 0 for color.
A nurse is discussing Apgar scoring with a newly licensed nurse. Which of the following information should the nurse include in the teaching? -Apgar scoring predicts future neurologic outcomes -Apgar scoring assesses the gestational age level of the neonate -Apgar scoring is a rapid assessment of the newborn's transition to extrauterine life -Apgar scoring should be done at 30 minutes following birth
-Apgar scoring is a rapid assessment of the newborn's transition to the extrauterine life
A nurse is discussing Apgar scoring with a newly licensed nurse. The nurse should identify that which of the following factors can affect the Apgar score? -Maternal medications -Gender of newborn -Use of internal fetal monitoring -Maternal age
-Maternal medications Rationale: maternal medications can affect Apgar scoring of the newborn. Other factors that can affect the Apgar score include the gestational age of the newborn, trauma during childbirth, hypovolemia, hypoxia, & congenital anomalies. The nurse should conduct the Apgar score at 1 minute & 5 minutes following birth.
A nurse is caring for a newborn immediately following birth. Which of the following actions should the nurse take first? -Place the newborn skin to skin on the mother's chest -Perform an Apgar score assessment on the newborn -Conduct a complete physical assessment of the newborn -Administer erythromycin eye ointment to the newborn
-Place the newborn skin to skin on the mother's chest Rationale: The greatest risk to this newborn is injury from hypothermia; therefore, the priority action is to place the newborn skin to skin on the mother's chest to assist with the newborn's transition to extrauterine life.
A nurse is conducting an Apgar score assessment on a newborn. Which of the following findings should the nurse assess? -Temp -BP -Resp effort -Gestational age
-Respiratory effort Rationale: Apgar scoring is a rapid assessment of the newborn's transition to extrauterine life & is based on 5 components: heart rate, respiratory effort, muscle tone, reflex irritability, & color. BP is NOT included in Apgar scoring.
