NCLEX Maternity Questions | Nurselytic

Questions 51

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NCLEX Maternity Questions Questions

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Question 1 of 5

At one minute after birth, a neonate is pink, except for blue extremities. The neonate is crying, gagging, and grimacing when the bulb syringe is used and has some flexion of extremities and an HR of 97. Based on the Apgar score, what should the nurse do next?

Correct Answer: B

Rationale: Rechecking the Apgar score at 5 minutes after birth will determine if the newborn is continuing to make a good transition to the extrauterine environment. Notifying the HCP is not necessary at this time. The one-minute Apgar score is 6, very close to the 7 to 10 normal limits. This newborn has a good cry, indicating good transition to the extrauterine environment thus far. Initiating resuscitation measures immediately is not necessary. This would be done if the newborn were not crying and demonstrated a blue or pale body. Swaddling and giving the newborn to the mother for breastfeeding are important but should occur after the 5-minute Apgar, if the score is WNL. Keeping this newborn in the radiant warmer, rather than giving him or her to the mother, will help prevent hypothermia and promote better transition to extrauterine life.

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