A nurse is caring for a client who is receiving oxytocin for the induction of labor and notes late decelerations of the fetal heart rate on the monitor tracing. The nurse should take which of the following actions?

The Apgar score is a method for assessing the health and well-being of a newborn baby immediately after birth. It is based on five criteria: appearance (skin color), pulse (heart rate), grimace (reflex irritability), activity (muscle tone), and respiration (breathing effort). Each criterion is given a score of 0, 1, or 2, depending on the baby's condition. The total score ranges from 0 to 10, with higher scores indicating better health. The Apgar score is determined at one and five minutes after birth, and sometimes at 10 minutes if the score is low or the baby needs resuscitation. The purpose of the Apgar score is to identify babies who need immediate medical attention and to monitor their response to treatment. The Apgar score is not a predictor of long-term outcomes or developmental problems .
One of the criteria that the nurse should measure when assigning an Apgar score is muscle tone. Muscle tone refers to the degree of tension or stiffness in the baby's muscles. It reflects the baby's neuromuscular function and oxygenation. Muscle tone can be assessed by observing the baby's posture, movement, and resistance to passive flexion or extension of the limbs .
The scoring system for muscle tone is as follows:
- Score 0: No movement; limp and floppy
- Score 1: Some flexion of arms and legs; weak or sluggish movement
- Score 2: Active movement; arms and legs flexed and resist extension
Therefore, the newly hired nurse who says that the nurse should measure the newborn's muscle tone
when assigning an Apgar score indicates an understanding of the teaching.

The other statements show a lack of knowledge or misunderstanding of the Apgar scoring:
- a) "The nurse should determine the Apgar score at 2 and 7 minutes after birth." This is not correct because the standard times for determining the Apgar score are one and five minutes after birth, not two and seven minutes. The one-minute score reflects how well the baby tolerated the delivery process, while the five-minute score reflects how well the baby adapted to the extrauterine environment .
- b) "The nurse should identify that the newborn is in severe distress with an Apgar score of 8." This is not correct because an Apgar score of 8 indicates that the newborn is in good condition and does not need any intervention. An Apgar score of 7 to 10 means that the newborn has normal vital signs and reflexes and only needs routine care. An Apgar score of 4 to 6 means that the newborn has moderate distress and may need some assistance with breathing or stimulation. An Apgar score of 0 to 3 means that the newborn has severe distress and needs immediate resuscitation .
- c) "The nurse should wait for the first Apgar score before initiating resuscitation efforts." This is not correct because waiting for the first Apgar score can delay life-saving interventions for a newborn who needs resuscitation. The nurse should initiate resuscitation efforts as soon as possible if the newborn shows any signs of distress, such as apnea, gasping, cyanosis, bradycardia, or poor muscle tone. The nurse should not rely on the Apgar score alone to decide whether to resuscitate or not, but use it as a tool to monitor the baby's response to treatment .

This is because a low pulse oximetry reading can indicate that the newborn is hypoxic and needs suctioning of the nasopharynx to clear any secretions that may be obstructing the airway²⁴. Hypoxia can cause bradycardia, acidosis, and brain injury in newborns, and should be corrected as soon as possible². The normal range of pulse oximetry for a newborn is 95% to 100%².

The other options are not correct because:
b) The newborn's respiratory rate is irregular
This is not a sign that suctioning is needed, as it is a normal finding in newborns. Newborns have periodic breathing patterns, which involve alternating periods of rapid and slow breathing, with occasional pauses of up to 10 seconds². This does not indicate respiratory distress or hypoxia, and does not require intervention unless the pauses are longer than 10 seconds or associated with cyanosis or bradycardia².
c) The newborn is beginning to cough
This is not a sign that suctioning is needed, as it is a normal reflex that helps the newborn clear the airway of secretions. Coughing can also stimulate breathing and prevent apnea in newborns². Coughing does not indicate respiratory distress or hypoxia, and does not require intervention unless it is persistent or associated with other signs of respiratory compromise².
d) The newborn's respiratory rate is 32/min
This is not a sign that suctioning is needed, as it is within the normal range for a newborn. The normal respiratory rate for a newborn is 30 to 60 breaths per minute². A respiratory rate that is too high or too low can indicate respiratory distress or hypoxia, and may require suctioning or other interventions².