A nurse observes 5 minutes after delivery that a newborn has a pink trunk and head, bluish hands and feet, and a heart rate of 130/min. He has flexed extremities and a weak, slow cry. The nurse should document what Apgar score for this infant?

Choice A reason:

Monitoring blood glucose levels is the priority intervention for a newborn who is small for gestational age (SGA). SGA infants are at a higher risk for hypoglycemia due to their limited glycogen stores and increased metabolic needs. Hypoglycemia can lead to serious complications such as seizures, brain damage, and even death if not promptly addressed. Therefore, frequent monitoring of blood glucose levels is crucial to ensure early detection and treatment of hypoglycemia, thereby preventing these adverse outcomes.

Choice B reason:

Monitoring intake and output is important for assessing the hydration status and renal function of the newborn. While this is a necessary aspect of care, it is not the priority intervention for an SGA infant. Ensuring adequate fluid intake and monitoring urine output helps in maintaining electrolyte balance and preventing dehydration, but it does not directly address the immediate risk of hypoglycemia, which is more critical in the initial care of an SGA newborn.

Choice C reason:

Monitoring weight is essential for tracking the growth and development of the newborn. Regular weight checks help in assessing the effectiveness of nutritional interventions and identifying any growth delays. However, this intervention is more relevant for long-term management rather than immediate care. The priority in the immediate postnatal period is to stabilize the infant’s condition, particularly by preventing hypoglycemia.

Choice D reason:

Monitoring axillary temperature is important to prevent hypothermia, which SGA infants are also at risk for due to their low body fat and poor thermoregulation. While maintaining a stable body temperature is crucial, it is not the most immediate concern compared to hypoglycemia. Hypoglycemia poses a more immediate threat to the infant’s

Choice A Reason:

Witnessing the signature for informed consent for surgery is important but not the immediate priority. The client’s vital signs indicate potential hemodynamic instability (low blood pressure and high heart rate), which requires prompt intervention to stabilize the client before any surgical procedures can be considered.

Choice B Reason:

Initiating IV access is the priority action. This allows for the administration of fluids and medications, which is crucial in managing the client’s hemodynamic status. The client’s low blood pressure and high heart rate suggest hypovolemia, likely due to significant blood loss. Immediate IV access enables rapid fluid resuscitation and preparation for potential blood transfusions, which are essential to stabilize the client1.

Choice C Reason:

Inserting an indwelling urinary catheter is necessary for monitoring urine output, which is an important indicator of renal perfusion and overall fluid status. However, it is not the immediate priority compared to establishing IV access, which directly addresses the client’s hemodynamic instability.

Choice D Reason:

Preparing the abdominal and perineal areas is a preparatory step for potential surgical intervention. While important, it is not the immediate priority. Stabilizing the client’s condition through IV access and fluid resuscitation takes precedence to ensure the client is in a stable condition for any subsequent procedures.