A neonate's 5-minute Apgar assessment reveals the following: active motion; pulse, 126 beats/minute; grimace and coughing during suctioning; appearance, good color all over; and respirations slightly irregular with weak cry
What action by the nurse is most appropriate?
A.
Assess oxygen saturation and administer oxygen if needed.
B.
Document the findings in the chart and begin the identification process.
C.
Facilitate bonding and help the mother initiate breastfeeding if desired.
D.
Place the baby in skin-to-skin contact on the mother's bare abdomen.
ANS: A
The baby's 5-minute Apgar score is 8 (motion, 2; pulse, 2; grimace, 2; appearance, 1; respirations, 1). If a 5-minute Apgar score is less than 9, the nurse should stabilize the infant instead of leaving the baby with the parents in the birthing unit. Because it appears that this baby's problems are related to either oxygenation or perfusion, the nurse should assess the oximetry reading and administer oxygen if needed.
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