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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?

A.

5.

B.

6.

C.

7.

D.

8.

E.

8.

Answer and Explanation

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 D

Explanation

Choice A rationale

Examining the tympanic membrane at the beginning may cause distress to the child and make the rest of the exam difficult.

Choice B rationale

Before auscultating the chest and abdomen, the child needs to be calm and cooperative, which might not be the case if their ear is examined first.

Choice C rationale

Examining the tympanic membrane before the head and neck could lead to increased anxiety and uncooperativeness in the child during the rest of the exam.

Choice D rationale

Examining the tympanic membrane at the end allows for a more accurate and complete examination without causing the child to become distressed early in the process.

Correct Answer is ["A","B","C","D"]

Explanation

Step 1 is to convert the child's weight from pounds to kilograms: 28 lb ÷ 2.2 lb/kg = 12.727 kg.

Step 2 is to calculate the dose: 10 mg/kg × 12.727 kg = 127.27 mg.

Step 3 is to determine how many mL is needed: 127.27 mg ÷ (120 mg/5 mL) = 5.3029 mL.

Step 4 is to round to the nearest tenth: 5.3 mL. Final answer: 5.3 mL

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