A nurse is caring for a newborn and calculating the Apgar score.

At 1 minute after delivery, the following findings are noted: heart rate of 110/min; slow, weak cry; flexed extremities; cries in response to suctioning of the nares; body pink in color with blue extremities.

Calculate the newborn’s Apgar score.

Choice A rationale

Given the neonate’s symptoms and critically low blood glucose level (30 mg/dL), the most urgent action is to address the hypoglycemia. Therefore, the nurse shouldadminister a bolus of intravenous glucose (Option A). This immediate intervention is crucial to stabilize the neonate and prevent further complications associated with hypoglycemia.

Choice B rationale

While monitoring blood glucose levels is important, waiting 30 minutes to reassess without immediate intervention could allow the hypoglycemia to worsen, potentially leading to severe complications such as seizures or brain damage. Immediate treatment is necessary to stabilize the neonate..

Choice C rationale

Although feeding can help increase blood glucose levels, the neonate’s current symptoms (jitteriness, poor feeding, weak cry, and irritability) suggest that they may not be able to effectively feed. Additionally, the blood glucose level is critically low and requires more rapid correction than feeding alone can provide..

Choice D rationale

While maintaining an appropriate body temperature is important, the neonate’s temperature (36.1°C) is not critically low. The primary concern here is the hypoglycemia, which needs to be addressed immediately. Placing the neonate under a radiant warmer does not directly address the low blood glucose level..

Choice A rationale

Drying the newborn’s skin thoroughly immediately after birth helps reduce heat loss by evaporation, which is a significant concern as wet skin can cause rapid heat loss.

Choice B rationale

Maintaining ambient room temperature at 24°C (75°F) helps prevent heat loss by convection but does not directly address evaporation.

Choice C rationale

Placing the newborn on a warm surface helps prevent heat loss by conduction but does not address evaporation.

Choice D rationale

Preventing air drafts helps reduce heat loss by convection but does not address evaporation.