A newborn, 1 minute after vaginal delivery, is pink with blue hands and feet, has a lusty cry, heartrate 180 beats/min, prompt response to stimulation with crying, and maintains minimal flexion, with sluggish movement. The nurse should know that this newborn's Apgar score is?

1. A

   10

2. B

   9

3. C

   8

4. D

   7

Appeared in: DHS Staff Nurse - 2018 (Shift-2nd)

Explanation

• The Apgar score is calculated by summing the scores of five criteria: Appearance, Pulse, Grimace, Activity, and Respiration.
• Appearance: The newborn is pink with blue hands and feet (acrocyanosis), which scores 1 point.
• Pulse: The heart rate is 180 beats/min, which is greater than 100 beats/min, scoring 2 points.
• Grimace: There is a prompt response to stimulation with a cry, scoring 2 points.
• Activity: The newborn has minimal flexion and sluggish movement, indicating some flexion, which scores 1 point.
• Respiration: A lusty cry indicates good respiratory effort, scoring 2 points.

Why Other Options Were Wrong

• Option A: A score of 10 requires the newborn to be completely pink (no acrocyanosis) and demonstrate active, vigorous motion. This newborn has blue extremities and minimal flexion.
• Option B: A score of 9 would mean only one point was deducted. This newborn lost one point for color (acrocyanosis) and another for muscle tone (minimal flexion), resulting in a total of 8.
• Option D: A score of 7 would indicate a greater degree of depression. This would require three points to be deducted. For example, if the newborn had a weak cry (1 point) in addition to acrocyanosis (1 point) and poor muscle tone (1 point).

Related Visual

Clinical Relevance

• Nursing practice connection: Safe nursing care depends on performing The concept tested is the calculation and interpretation of the Apgar score for a newborn immediately after delivery in the correct sequence, documenting the action clearly, and monitoring for the expected response.
• The Apgar score is a critical tool for nurses to quickly assess a newborn's transition to extrauterine life and determine the need for resuscitation. It provides a standardized method for communication among the healthcare team.
• A score of 7-10 is considered normal and usually requires only routine care like warming, drying, and clearing the airway if needed. A score of 4-6 indicates moderate depression requiring some assistance, such as stimulation or oxygen. A score below 4 indicates severe depression requiring immediate resuscitation.
• The score is assessed at 1 minute and 5 minutes. The 1-minute score reflects the infant's condition immediately after birth, while the 5-minute score is more indicative of the infant's response to resuscitation and overall prognosis.

How to Approach the Question

• First, identify the core task: calculating an Apgar score based on a clinical scenario.
• Recall the five components of the Apgar score using the mnemonic APGAR: Appearance, Pulse, Grimace, Activity, and Respiration.
• Systematically read the newborn's description and assign a score of 0, 1, or 2 for each of the five components.
• Appearance: 'pink with blue hands and feet' is acrocyanosis, which scores 1.
• Pulse: 'heartrate 180 beats/min' is over 100, which scores 2.
• Grimace: 'prompt response to stimulation with crying' is a vigorous response, which scores 2.

Concept Tested & Keywords

• Concept Tested: The concept tested is the calculation and interpretation of the Apgar score for a newborn immediately after delivery.
• Stem keywords: newborn, 1 minute, vaginal delivery, pink with blue hands and feet, heartrate 180 beats/min, lusty cry, prompt response to stimulation, minimal flexion
• Lead-in keywords: The nurse should know that this newborn's Apgar score is?
• Clinical cues: The combination of a pink body with blue extremities (acrocyanosis) and minimal flexion are key indicators that the score will be less than 10.

Question ID

Qu8Mf8YYc_m6JAGxb36cyR

Copy ID

Reference Book

E6 Obstetrics Williams p. 3

E6 Ghai Essential Pediatrics(pp 26-904 of 913) p. 118-120