Question

An infant's Apgar score is 9 at 5 minutes. The nurse is aware that the most likely cause for the deduction of one point is: A. The baby is cold. B. The baby is experiencing bradycardia. C. The baby's hands and feet are blue. D. The baby is lethargic.

Short answer

Answer: The most likely cause for a deduction of one point when a newborn's Apgar score is 9 at 5 minutes is that the baby's hands and feet are blue, which affects the color component of the Apgar score.

Step-by-step solution

Understanding the Apgar Score Components

The Apgar score is determined based on five components: heart rate, respiratory effort, muscle tone, reflex irritability, and color (skin appearance). Each component is scored 0, 1, or 2, with a total possible score of 10 (perfect score).

Evaluating Each Answer Choice

We will go through each answer choice to determine which one is the most likely reason for the point deduction, considering the five components of the Apgar score. A. The baby is cold: While cold stress can potentially cause poor reflexes or muscle tone, a cold baby doesn't automatically receive a point deduction from the Apgar score, so this is not the most likely reason. B. The baby is experiencing bradycardia: Bradycardia refers to a slow heart rate. A low heart rate would affect the heart rate component of the Apgar score. However, since the baby received a 9 out of 10, having bradycardia could potentially bring the score much lower. C. The baby's hands and feet are blue: This can be a sign of mild cyanosis, which affects the color component of the score. Cyanosis (blue appearance) of hands and feet is relatively common and can be scored as 1 (instead of 2) in the Apgar scoring system. This may be the most likely reason for one point deduction. D. The baby is lethargic: Lethargy could affect multiple components of the Apgar score, such as muscle tone and reflex irritability. However, a lethargic baby may have a lower total score than 9.

Selecting the Most Likely Answer

After analyzing all the answer choices, it seems that option C (The baby's hands and feet are blue) is the most likely reason for the deduction of one point, as it affects the color component of the Apgar score and is relatively common in newborns.