A nurse is caring for a pregnant client in labor in a health care facility.
The nurse knows that which sign indicates that the patient is no longer in the first stage of labor?

The correct answer is choice C.

Choice A rationale:

A 1-minute Apgar score of 5 points does not necessarily indicate a congenital heart defect or an immature respiratory system.

Choice B rationale:

An Apgar score of 5 points at 1 minute does not require immediate and aggressive interventions for survival.

Choice C rationale:

A 1-minute Apgar score of 5 points indicates that the infant is experiencing moderate difficulty in adjusting to extrauterine life.

Choice D rationale:

An Apgar score of 5 points at 1 minute does not indicate that the infant is adjusting well to extrauterine life.

The correct answer is choice C.

Choice A rationale:

While it’s important to monitor a newborn’s glucose level, it’s not the immediate priority following birth.

Choice B rationale:

Placing the infant in the bassinet is not the immediate priority. The newborn needs to be dried and warmed first to prevent hypothermia.

Choice C rationale:

Drying the newborn and placing it skin-to-skin on the mother helps prevent hypothermia and promotes bonding. This is the immediate priority.

Choice D rationale:

A full head-to-toe assessment is important, but it’s not the immediate priority following birth.