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. Asking a psychiatrist to talk with the parents may not be the most appropriate immediate

action when abuse is suspected. Reporting to the authorities should take precedence to ensure the child's safety.

B. Obtaining a detailed history is important but should be done after reporting the suspected abuse to the authorities.

C. Separating the child from the parents may not be feasible or appropriate in all situations.

Reporting to the authorities is the priority action to ensure proper investigation and protection of the child.

D. Report the suspected abuse to the authorities. Suspected child abuse must be reported

immediately to the appropriate authorities, such as child protective services or law enforcement, for further investigation and intervention to ensure the safety and well-being of the child.

A. Abundant lanugo is incorrect because postmature newborns typically lose their lanugo before birth.

B. Vernix in the folds and creases is incorrect as vernix caseosa, the white, cheese-like substance covering the skin of the fetus, is often absent in postmature newborns due to it being absorbed as the gestation period extends beyond the normal term.

C. Short, soft fingernails are not expected in postmature newborns; instead, they may have long, overgrown nails.

D. Cracked, peeling skin is a common finding in postmature newborns due to prolonged exposure to amniotic fluid and a decrease in the protective vernix caseos

A.

E. A positive Moro reflex is a normal finding in newborns, including those who are postmature, indicating a healthy neurological response.