The nurse conducting a 5-minute Apgar assessment on a newborn assigns the following ratings:
Heart rate < 100 beats per minute (1 point); slow, irregular respirations (1 point); some flexion of the extremities (1 point); a vigorous cry with flicking of the baby's foot (2 points); and a pink body with blue extremities (1 point). Based on this data, which nursing action is appropriate?
A) Having the aide reassess the newborn's heart rate and respiratory rate when admitted to the nursery
B) Swaddling the newborn to decrease the risk of increased energy expenditure
C) Placing the newborn in the mother's arms and asking her to monitor her baby's breathing
D) Repeating the assessment every 5 minutes for up to 20 minutes
Answer: D
With a 5-minute Apgar of 6, this newborn is at increased risk for complications compared to those with Apgar scores in the range of 7 to 10. The nurse will reassess the client every 5 minutes for up to 20 minutes. The nurse should have resuscitative equipment ready for use. The other actions are not appropriate based on the data provided.
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