The home care nurse is examining a newborn. The newborn is noted ...

[abern]

The home care nurse is examining a newborn. The newborn is noted to be sleeping in a basket on a pillow with a stuffed animal, a fluffy blanket covering the infant. The most important nursing action is to:
 
  1. Remove the stuffed animal from the basket and place it on the floor.
  2. Teach the parents the risk of SIDS from soft items in the infant's bed.
  3. Make certain that the blanket is firmly tucked under the baby.
  4. Ask if the color of the blanket has cultural significance.

Question 2

At 1 minute after birth, the infant has a heart rate of 100 bpm, and is crying vigorously. His limbs are flexed, his trunk is pink, and his feet and hands are cyanotic. The infant cries easily when the soles of his feet are stimulated.
 
  How would the nurse document this infant's Apgar score? 1. 7
  2. 8
  3. 9
  4. 10

[Carliemb17]

Answer to Question 1

2
Rationale:
1. Both the fluffy blanket and the stuffed animal increase the risk of SIDS. Both should be removed after the parents are taught that these items are safety hazards.
2. This is the highest priority.
3. A fluffy blanket should not be used. The parents need education on fluffy items' being a health hazard.
4. Cultural significance is important, but physical safety of the newborn is a higher priority.

Answer to Question 2

3
Rationale: Two points each are scored in the categories of heart rate, respiratory effort, muscle tone, and reflex irritability. One point is scored in the category of skin color. The total Apgar would be 9.