What is the Apgar score for the infant whose findings are heart rate 120 bpm, crying vigorously, actively moving extremities, blue hands and feet, and sneezed upon suctioning with bulb suction?

Correct Answer: C

Rationale: The Apgar score assesses newborns' overall health at 1 and 5 minutes after birth. Each category (heart rate, respiratory effort, muscle tone, reflex irritability, color) is scored 0-2. In this case, the infant's findings indicate a heart rate of 120 bpm (2 points), vigorous crying (2 points), active movement of extremities (2 points), blue hands and feet (1 point), and sneezing (2 points). Adding these scores together, the total is 9 (2 + 2 + 2 + 1 + 2 = 9). Therefore, the correct answer is C: Score of 9. Other choices are incorrect because they do not accurately reflect the individual scores given in the scenario.

Correct Answer: D

Rationale: The correct answer is D: Fontanels that feel soft and flat. This indicates dehydration or a problem with intracranial pressure. Soft and flat fontanels in a newborn are concerning as they should be slightly elevated and have a slight pulsation. The nurse should further investigate this by checking for signs of dehydration or increased intracranial pressure. A: A temperature of 97.5°F axillary is within the normal range for a newborn. B: Respirations of 60 breaths per minute while sleeping soundly are normal for a newborn. C: Acrocyanosis in a baby born 6 hours ago is a common finding in newborns and usually resolves on its own.

Correct Answer: B

Rationale: The correct answer is B: Vitamin K was given to prevent hemorrhagic disease. Vitamin K is routinely given to newborns to prevent hemorrhagic disease of the newborn, which is a condition that can lead to severe bleeding. This is a standard practice shortly after birth to ensure the baby has enough clotting factors. Incorrect Choices: A: Clindamycin is not routinely given to newborns to prevent eye infections from sexually transmitted infections. C: Haemophilus influenzae vaccine is typically given later in infancy to prevent Haemophilus influenzae infections, not the flu. D: Rotateq is a vaccine for rotavirus to prevent gastrointestinal illness, but it is not typically given immediately after birth.

Correct Answer: D

Rationale: The correct answer is D because moderate retractions at rest indicate increased work of breathing, which is a sign of respiratory distress in a neonate not transitioning well to extrauterine life. Retractions signify the body's effort to maintain adequate oxygen levels. A is incorrect because brief periods of periodic breathing are normal in neonates. B is incorrect as central pink coloring indicates adequate oxygenation despite blue extremities. C is incorrect because a respiratory rate of 50 breaths per minute is within the normal range for a neonate and does not necessarily indicate transition issues.

Correct Answer: A

Rationale: The correct answer is A: Maternal fever. Maternal fever can lead to increased heat transfer to the infant, causing higher body temperature and increased risk of hypothermia. Fever in the mother can disrupt the infant's thermoregulation mechanisms, making them more susceptible to hypothermia. Neutral ambient environment (B) is not a risk factor for hypothermia unless it is too cold. Large for gestational age (C) infants may have more body fat which can help with heat retention. Jaundice (D) does not directly increase the risk of hypothermia.