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?
5.
6.
7.
8.
8.
The Correct Answer is C
Choice A rationale
An APGAR score of 5 indicates significant distress and poor adjustment to extrauterine life, which is not consistent with the provided description of the infant's condition.
Choice B rationale
An APGAR score of 6 suggests moderate difficulty with extrauterine adaptation, which is still not entirely consistent with the overall assessment of the infant.
Choice C rationale
An APGAR score of 7 aligns with the described observations of the newborn: pink trunk and head, bluish extremities, active movement, heart rate of 130/min, and a response to
suctioning, which suggest the infant is in reasonably good condition with some minor issues that need monitoring.
Choice D rationale
An APGAR score of 8 would indicate that the newborn is in very good condition with only slight adjustments needed, which does not fully match the infant's description with the noted
issues like a weak cry and bluish extremities.
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Correct Answer is A
Explanation
Choice A rationale
Monitoring for hypoglycemia is critical in newborns born to mothers with gestational diabetes, as they can experience significant drops in blood sugar levels post-birth due to the
sudden discontinuation of the high glucose supply from the mother.
Choice B rationale
Physiological jaundice is common in many newborns but does not represent the most immediate threat. It typically resolves within a few days with appropriate monitoring and care.
Choice C rationale
Hyperthermia can be a concern for newborns, but it is not the primary immediate complication in newborns born to gestational diabetic mothers. Hypoglycemia poses a greater
immediate risk.
Choice D rationale
Development of rash is generally a less critical concern and does not represent an immediate threat to the newborn’s well-being in comparison to hypoglycemia.
Correct Answer is D
Explanation
Choice A rationale
Administering vitamin K is important but not the immediate priority right after birth.
Choice B rationale
Administering eye prophylaxis is also necessary but comes after ensuring the newborn is dry to prevent heat loss.
Choice C rationale
Placing an identification bracelet is crucial but not as immediate as drying the skin to regulate the baby's temperature.
Choice D rationale
Drying the skin is the priority to prevent hypothermia by reducing evaporative heat loss right after birth