Newborn

1.
Which action should the nursery nurse take first in caring for the infant?
A) Dry the infant quickly with warm blankets.
CORRECT
Drying the infant is a priority to prevent evaporative heat loss.

B) Use a scale to immediately weigh the infant.
INCORRECT
Weighing the infant can be delayed and another intervention done first.

C) Apply a servomechanism temperature probe.
INCORRECT
Applying a temperature probe is a common procedure when using a radiant warmer; however, another action should come first.

D) Cover the infant's head using a soft cap.
INCORRECT
Another action should be taken first.

After clearing the airway and drying the infant, the nurse assesses that the infant is breathing and has a heart rate of 100, but remains cyanotic.

2.
What action should the nurse take?
A) Apply temperature probe.
INCORRECT
Further action is needed.

B) Prepare to give oxygen.
CORRECT
The infant is breathing and has a heart rate. However, oxygen given during this critical transition can increase oxygenation to the rest of the body. Oxygen is usually given by having the nurse cup her hands around the infant's nose and mouth at the O2 tube.

C) Wrap the infant warmly.
INCORRECT
Wrapping the infant is not the best response for this situation.

D) Secure a suction catheter.
INCORRECT
Further suctioning is not needed since the infant is breathing on his own. Another response is best.

At 1 minute the infant has a heart rate of 142, a slow weak cry, is grimacing, and is in a flexed position with acrocyanosis.

3.
What Apgar score should the nurse assign?
A) 10.
INCORRECT
This score is not correct.

B) 9.
INCORRECT
This score is not correct.

C) 7.
CORRECT
One point each is deducted for acrocyanosis (blue hands and feet), a slow weak cry and grimacing.

D) 8.
INCORRECT
This score is not correct.

4.
Which action should the nurse take prior to weighing the infant?
A) Provide a pacifier.