A nurse is caring for a newborn and calculating the Apgar score. At 1 min after delivery, the following findings are noted: heart rate of 110/min; slow, weak cry, some flexion of extremities; grimace in response to suctioning of the nares; body pink in color with blue extremities.

Calculate the newborn's Apgar score.

Rationale:

A. While covering the cord with a sterile, moist saline dressing is important, it is not the first priority when the umbilical cord is prolapsed.

B. While preparing for an immediate birth may become necessary, the first action should be to relieve pressure on the cord to prevent cord compression and compromise to fetal circulation.

C. This is the priority action to prevent cord compression and maintain fetal oxygenation.

D. Placing the client in the knee-chest position can help relieve pressure on the cord, but the nurse's immediate action should be to manually support the cord while awaiting further

instructions from the healthcare provider.

A. Frequent use of the call light does not necessarily indicate abuse. It could be due to various factors such as pain, discomfort, or needing assistance.
B. A child whose parents answer questions for the child may indicate potential parental control or intimidation, which can be a sign of emotional or psychological abuse.

C. Obesity alone does not necessarily indicate abuse. It could be due to various factors such as genetics, diet, or lack of physical activity.
D. Having frequent visitors does not necessarily indicate abuse. It could be due to a supportive social network or family involvement.