The nurse is caring for a 12-month-old diagnosed with chronic lung disease, receiving supplemental oxygen with a portable oxygen tank. What developmental milestone is likely to be delayed?

The APGAR score assesses five criteria: Appearance (skin colour), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration (breathing effort). Each criterion is scored from 0 to 2, with a maximum total score of 10.

• Appearance: The infant is pale, which scores 0.
• Pulse: The heart rate is 99 beats per minute, which scores 1 (as it is below 100).
• Grimace: No response to stimulus, which scores 0.
• Activity: The infant is limp, which scores 0.
• Respiration: No spontaneous respirations, which scores 0.

Summing these scores gives a total APGAR score of 1.

Choice A reason: While nausea, tiredness, and sleepiness are common during the first trimester of pregnancy, they are typically not signs of an immediate emergency. This patient does not exhibit any alarming symptoms that would require immediate hospital referral.

Choice B reason: Blurred vision and seeing spots during pregnancy can be symptoms of preeclampsia, a potentially dangerous condition characterized by high blood pressure. Preeclampsia can pose serious health risks to both the mother and the baby and requires immediate medical attention.

Choice C reason: Frequent urination is a common symptom in the later stages of pregnancy due to the pressure the growing baby exerts on the bladder. This symptom alone does not indicate an immediate need for hospital evaluation.

Choice D reason: Having 4 to 5 contractions in an hour at 37 weeks of pregnancy can be a sign of early labor. However, unless the contractions are persistent and intensifying, this may not necessitate an immediate hospital referral. The nurse would likely advise the patient to monitor the contractions and come in if they continue or become stronger.