Erin gives birth to a boy. The nurse notes the following on the baby at 1 minute: heart rate is 138 bpm, loud vigorous crying, spontaneous movement and flexion of the extremities, and pink skin color except for a bluish color of the hands and feet. What Apgar score will be assigned to the baby?

Choice A reason:

This is the best response because it shows that the nurse is providing nonpharmacological pain relief measures and supporting the client's coping mechanisms. Breathing and imagery techniques can help the client relax and focus on something other than the pain. Moaning, screaming, and vocalizing are normal and acceptable ways of expressing pain during labor, and the nurse should not try to suppress them.

Choice B reason:

This is not the best response because it does not address the husband's concern or offer any intervention for the client's pain. Asking the client to rate her pain on a scale of 0 to 10 is a subjective assessment tool that may not reflect the true intensity of her pain. Furthermore, it may be difficult for the client to answer this question while she is in the second stage of labor.

Choice C reason:

This is not the best response because it may not be feasible or appropriate to administer more pain medication to the client in the second stage of labor. The obstetrician may not be available to evaluate the client's pain, and increasing the dose of pain medication may have adverse effects on the client and the fetus, such as respiratory depression, hypotension, and decreased uterine contractility.

Choice D reason:

This is not the best response because it does not acknowledge the husband's feelings or provide any comfort or education for him. Reassuring him that his wife will be fine may sound dismissive and insensitive, and offering to stay with her while he takes a walk may imply that he is not needed or wanted in the birthing room. The nurse should involve the husband in the care of his wife and explain to him what is happening and what to expect during labor.

Choice A reason:

This is incorrect because WIC does not provide immunizations for high-risk infants and children. Immunizations are provided by other health care services, which WIC may refer participants to.

Choice B reason:

This is incorrect because WIC does not screen for infants with developmental disorders. WIC provides nutrition education and referrals to other health and social services but does not diagnose or treat any medical conditions.

Choice C reason:

This is correct because WIC provides supplemental food supplies to low-income pregnant or breastfeeding women, as well as infants and children up to age 5 who are at nutritional risk. The food packages are designed to meet the special nutritional needs of the participants and include items such as fruits, vegetables, milk, cheese, cereal, bread, juice, peanut butter, eggs, and infant formula.

Choice D reason:

This is incorrect because WIC does not provide well-child examinations for infants and children living at the poverty level. WIC may refer participants to other health care services that provide such examinations but do not conduct them themselves.