Question

You are a nurse in the special care nursery and are paged to delivery room 5. The labor nurse tells you that the baby has been stuck in the birth canal for a while and now the fetal heart tones are down. Vacuum suction is being used to assist in the delivery. The doctor gets the baby out and places the infant on the radiant warmer. You are the resuscitating nurse for the infant and you observe that the infant is limp, pale, and gasping, with poor tone; the heart rate is 101.

1. What are your first actions to aid in this infant’s recovery?

2. What Apgar score would you assign at 1 minute with these results? Explain the score for each category.

3. At 5 minutes the infant is now moving vigorously and has a good strong cry, the heart rate is 120, and the hands and feet are bluish in color, moves away when trying to suction the mouth and nose. What is the APGAR score? According to the APGAR what would be the priority in care for this infant?

4. What would you explain to the mother about the delivery and everything that was completed?

Answer 1

1. What are your first actions to aid in this infant’s recovery?

Providing adequate ventilation is the primary action in this infant's recovery. Resuscitate the infant by initiating suctioning to clear airway helps to achieve regular respiration on the infant.

2. What Apgar score would you assign at 1 minute with these results? Explain the score for each category.

APGAR score at 1 minute:

Activity - Limpiness - 0

Pulse - over 100 beats per minute - 2

Grimace - No stimuli - 0

Appearance - pale - 0

Respiration - slow and irregular - 1

Total score of APGAR = 3

A low APGAR score gives warning signals that the infant requires immediate resuscitation.

3. APGAR score at 5 minutes

Activity - vigorous movement - 2

pulse - over 100 minute - 2

Grimace - strong cry - 2

Appearance - hands and feet are blue - 1

Respiration - good - 2

Total APGAR score = 9

Apgar score is good for the infant. The priority is to continue with resuscitation.

4. What would you explain to the mother about the delivery and everything that was completed?

The team should be met with the nurse and explained the complications that arrived during delivery and efforts taken for the well-being of mother and baby. Explain the baby's condition during delivery and need of resuscitation for the survival of the baby. Explain about the improvement of the baby following resuscitation and the protocols followed for the complete cure of baby.