Question

A certified nurse-midwife places a neonate under the radiant heat unit for the nurse's initial assessment. The initial assessment includes heart rate 110 beats/minute and an irregular respiratory effort. The neonate is moving all extremities and his body is pink. He also has a vigorous cry. The nurse notes copious amounts of clear mucus present both orally and nasally. Based on these assessment findings, what should the nurse do next

Answer 1

clean all mucus and perscribe a medicine

Answer 2

The nurse should record an Apgar score of 9 for this newborn and should start an aspiration to remove mucus from the nasal and oral cavities and to improve the newborn's breathing.

Step-by-step explanation:

In order to assess newborn vitality, the Apgar test was created in 1952 by US anesthetist Virginia Apgar and became popular worldwide as an easy and reliable method for determining early infant care. The test is based on five assessment criteria: heart rate, respiration, muscle tone, reflex readiness and skin color, which individually can score from 0 to 2, with a total of 10 points.

Since the baby shown in the above question is pink in color, cries vigorously, moves all extremities, has a heart rate of 110 beats / minute, and has an irregular breathing effort, he should receive a score of 9 on the Apgar test.

Babies who have an Apgar score between 8 and 10 are considered healthy, fit, and not suffocated.

However, the baby shown in the question has mucus in the nasal and oral cavities and is breathing irregularly. This indicates that the baby needs to have an aspiration to solve these problems.