A nurse is reinforcing teaching about umbilical cord care with a client who is postpartum.
Which of the following instructions should the nurse include?

A nurse is assisting in the care of a newborn following birth. At 1 min after birth, the nurse notes the following: heart rate 110/min; slow, weak cry; some flexion of extremities; responds to suctioning of the nares with respiration of 20; body pink in color with blue extremities. What should the nurse document as the newborn's 1-min Apgar score? The correct answer is choice B: 7.
Choice A rationale:

Apgar scores are determined by assessing five vital signs in a newborn at 1 and 5 minutes after birth. The vital signs are heart rate, respiratory effort, muscle tone, reflex irritability, and color. Each category is scored from 0 to 2, with 2 being the best score. In this case, the heart rate is 1, the respiratory effort is 1, muscle tone is 1, reflex irritability is 2 (as the newborn responds to suctioning), and color is 2 (as the body is pink). Therefore, the total Apgar score is 7 (1 + 1 + 1 + 2 + 2 = 7).

Choice B rationale:

The heart rate at 1 minute is 110 beats per minute, which is considered normal for a newborn. A slow, weak cry suggests some respiratory effort, which is given a score of 1 on the Apgar scale. Some flexion of extremities also indicates moderate muscle tone and receives a score of 1. Responding to suctioning with respiration indicates good reflex irritability, which is given a score of 2. The body being pink in color is a positive sign for oxygenation and receives a score of 2. Adding up these scores (1 + 1 + 2 + 2) equals 7, which is the 1-minute Apgar score.

Choice C rationale:

Apgar scores are not determined based on gestational age; they focus on the newborn's immediate condition. While gestational age can influence a newborn's health, it is not directly factored into the Apgar score.

Choice D rationale:

The Apgar score is not related to the mother's condition or complications during pregnancy, such as placenta previa. It solely evaluates the newborn's condition at 1 and 5 minutes after birth.

Choice E rationale:

The Apgar score is a quick assessment of the newborn's physical condition and does not consider issues like the mother's gestational diabetes. It focuses on the baby's vital signs and physical appearance to gauge overall well-being.

The correct answer is choicea. “I should stimulate my nipples by squeezing softly.”

Choice A rationale:

Stimulating the nipples by squeezing them can encourage milk production, which is not recommended for a client who is bottle feeding and trying to reduce breast engorgement.

Choice B rationale:

Applying ice packs to the breasts can help reduce swelling and provide relief from engorgement.

Choice C rationale:

Wearing a snug-fitting bra can help support the breasts and reduce discomfort associated with engorgement.

Choice D rationale:

Placing crushed cabbage leaves on the breasts is a common home remedy that can help reduce swelling and discomfort from engorgement.