Problem
• Baby J has just been delivered and it is time for one minute APGAR. She has a strong lusty cry when stimulated, pink body with blue hands and feet. She is fully flexed with a heartbeat of 99. What APGAR would you assign?
• What important interventions should the nurse keep in mind?
• She is now 5 minutes old and her heart rate is 120, respiratory effort remains strong, with grimacing when stimulated. Her hands and feet remain dusky and fully flexed extremities. What APGAR would you assign? What does this indicate and what do we further need to assess?
• She was 8# 11 oz. at delivery, delivered vaginally. She has been breastfeeding every 1-2 hours for 10 minutes per side but the mother provides a supplemental feeding of 45 minutes after each breastfeeding. The infant is alert and sucks well and has occasional "spit-ups". Is this concerning?
• During your assessment, you note swelling of the baby's head that crosses suture lines, dark gray markings above the buttocks, white bumps on her nose, and swollen breast busy and labia. What do you explain to the mom about this and how is she to care for her baby?
• The mother is concerned about the dark, tarry appearance of the baby's stool and curious as to when that appear "normal" and how often she should stool and have wet diapers from here on out. What is the best response?
• You are called into the room because the mother is concerned with the sporadic breathing pattern of the baby. The mother has the infant unwrapped, lying on her bed, the infant appears lethargic, limbs relaxed at her side, with some noticeable jitters that cease upon touching the infant. You attempt to arouse the infant, but efforts are short-lived, and you have difficulty getting her to stay awake long enough to eat. What actions should be performed by the nurse?