Term 47 |
The certified nurse midwife places the neonate under the radiant heat unit for the nurse's initial assessment. The initial assessment includes heart rate 110 beats/minute and an irregular respiratory effort. The neonate is moving all extremities and his body is pink. He also has a vigorous cry. The nurse notes copious amounts of clear mucus present both orally and nasally. Based on these assessment findings, what should the nurse do next? 1. Assign an Apgar score of 7, place the neonate in modified Trendelenburg position, and begin artificial respirations. 2. Assign an Apgar score of 6, place in the neonate in modified Trendelenburg position, and initiate a code to gain assistance from the code team. 3. Assign an Apgar score of 9, place the neonate in modified Trendelenburg position, and suction the neonate's nose and oropharynx. 4. Assign an Apgar score of 10, place in the neonate in modified Trendelenburg position, and suction the neonate's nose.
|
|
|
Definition 47 |
RATIONALES: The neonate should be assigned an Apgar score of 9 because the neonate is pink, is crying vigorously, is moving all extremities, has a heart rate of 110 beats/minute, and has an irregular respiratory effort. The irregular respiratory effort and the presence of mucus in the nasal and oral cavities signify that the neonate requires suctioning. The neonate doesn't require resuscitation.
|
|
|
|
Term 48 |
At 5 minutes of age, a neonate is pink with acrocyanosis, has his knees flexed and fists clinched, has a whimpering cry, has a heart rate of 128, and withdraws his foot when slapped on the sole. What 5-minute Apgar score would the nurse record for this neonate? Sign Apgar Score 0 1 2 Heart rate Absent Less than 100 beats/minute (slow) More than 100 beats/minute Respiratory effort Absent Slow, irregular Good crying Muscle tone Flaccid Some flexion and resistance to extension of extremities Active motion Reflex irritability No response Grimace or weak cry Vigorous cry Color Pallor, cyanosis Pink body, blue extremities Completely pink
|
|
|
Definition 48 |
RATIONALES: Apgar consists of a 0 to 2 point scoring system for a neonate immediately following birth and at 5 minutes of age. The nurse evaluates the neonate for heart rate, respiratory effort, muscle tone, reflex irritability, and color. This neonate has a heart rate above 100, which equals 2; pink color with acrocyanosis, which equals 1; is well-flexed, which equals 2; has a weak cry, which equals 1; and has a good response to slapping the soles of the feet, which equals 2. Therefore, the nurse should record a total Apgar score of 8 |
|
|
|