Care of the Premature,

Postmature, and Sick

Infant

Terminology

Assessment

Nursing Interventions

Neonatal Resuscitation

Objectives

� Define premature, postmature, SGA,

LGA, low birth weight infants.

� Assess the premature and postmature

infant.infant.

� Examine the steps of the Neonatal

Resuscitation Program

� Review nursing interventions for delivery

care, hypothermia, respiratory distress,

and hypoglycemia

Terminology

� Premature infant: < 38 weeks gestation

� Low birth weight: < 2500 Gm regardless of gestational age

Moderately low birth weight: 1501-2500 � Moderately low birth weight: 1501-2500 Gm

� Very low birth weight: < 1500 Gm

� Extremely low birth weight: < 1000 Gm

Terminology

� Postmature infant: 42 weeks gestation

or greater

� Small for gestation age: < 10% on

growth chart

� Large for gestation age: above 90% on

growth chart

Premature Infant

� Infant born < 38 weeks gestation

� Factors contributing to premature birth are:

� Incompetent cervix

Multiple gestation� Multiple gestation

� Premature rupture of membranes

� Adolescent pregnancy

� Maternal hypertension (preeclampsia)

� Maternal infection or disease

� History of premature deliveries

Premature Infant

� Problems of premature infant:

� Hypoglycemia

� Hypothermia

� Respiratory distress syndrome

� Infection

� Neurological problems (intraventricular hemorrhage)

� Necrotizing enterocolitis

� Problems related to immaturity of every body system

Premature Infant

� Assessment:

� Thin, gelatinous skin< 26 weeks, bright pink in color

� Presence or absence of lanugo, plantar creases, breast tissue, ear cartilage

� Eyes fused < 24 weeks

� Soft cranium, hair is fine

� Lack subcutaneous fat

� Head large in proportion to body

� Female – prominent clitoris and labia

� Male – nondescended testes, few rugae

� Immature reflexes

Premature Infant

�� Pictures courtesy Pictures courtesy

of Yahoo!of Yahoo!

FIGURE 30–6 A 6-day-old, 28-

week gestational age, 960-g preterm

infant.

Postmature Infant� Infant born > 42 weeks gestation

� Placenta has lost ability to provide sufficient nutrients and oxygen and to eliminate waste products.

� Problems of postmature infant are:� Meconium aspiration

� Malnutrition, hypoglycemia

� Hypothermia

� Asphyxia, Death

Postmature Infant

� Assessment:

� Dry, cracking skin

� Absence of vernix and lanugo

� Extremities may be long and thin

� Long fingernails� Long fingernails

� Skin may be deep yellow or green from meconium

� Abundant scalp hair

� Thin appearance due to loss of subcutaneous fat

Postterm Infant

FIGURE 30–5 Postterm

infant demonstrates deep

cracking and peeling of skin.

Nursing Interventions

with the Preterm,

Postterm, and Sick

InfantInfant

Delivery NRP Admission to

Nursery/NICU

Nursing Interventions at Delivery

and Admission to Nursery/NICU

� Place under radiant warmer at 36.5C

� Dry and stimulate with warm blankets

� Obtain vital signs� Obtain vital signs

� Apply O2 – bag & mask, ventilate

� Suction as needed

� Obtain 1 minute, 5 minute, 10 minute

APGAR scores

� Assess umbilical cord – 3 vessels

Nursing Interventions at Delivery

and Admission to Nursery/NICU

� Place ID bands on

� Obtain footprint

� Allow mother to see newborn� Allow mother to see newborn

� Transport to Nursery or NICU

� Obtain weight & length

� Complete physical and gestational

age assessments

� Administer erythromycin ointment and

vitamin K

Neonatal Resuscitation

Program (NRP)

� At delivery, ask 4

questions:

� Term gestation?

� Clear amniotic

� Routine care

� Provide warmth

� Clear airway

� Dry

Yes

� Clear amniotic

fluid?

� Breathing or

crying?

� Good muscle

tone?

� Dry

� Assess color

� Provide warmth

� Position, clear airway

� Dry, stimulate,

reposition

� Evaluate respirations,

heart rate, color

No

Neonatal Resuscitation

Program (NRP)

� Evaluate

respirations, heart

rate, color

� Breathing

� HR > 100 Observe

� Pink

Yes

� Cyanotic – give

supplemental oxygen

� Apneic or PPV

� HR < 100

� HR < 60 – Chest

compressions,

epinephrine

Bag/Mask Ventilation

�� Use a cushioned, anatomically Use a cushioned, anatomically shaped maskshaped mask

�� Mask must cover Mask must cover nose and mouth nose and mouth nose and mouth nose and mouth completelycompletely

�� Bottom rim should Bottom rim should cover the edge cover the edge of the chinof the chin

� Place thumb over the nose portion of the mask

� Watch for chest rise while squeezing the bag

� If chest does not rise

1.1. Recheck sealRecheck seal

2.2. Reposition headReposition head

3.3. Increase inflating Increase inflating pressurepressure

Assisting with Intubation

�� Hold the suction catheter Hold the suction catheter close to the operatorclose to the operator

�� Provide oxygenProvide oxygen�� Provide oxygenProvide oxygen

�� Check tube cm markingCheck tube cm marking

at lipat lip

�� Place a gastric tube Place a gastric tube to decompress the to decompress the stomachstomach

ET Tube Location on CXR

Optimal ET Optimal ET tube locationtube locationOptimal ET Optimal ET tube locationtube location

CarinaCarinaCarinaCarina

tube locationtube locationtube locationtube location

© S.T.A.B.L.E.®

© S.T.A.B.L.E.®

ET tube in ET tube in acceptable acceptable

positionposition

ET tube in ET tube in acceptable acceptable

positionposition

© S.T.A.B.L.E.®

© S.T.A.B.L.E.®

ET tube ET tube in right in right mainstem mainstem bronchusbronchus

ET tube ET tube in right in right mainstem mainstem bronchusbronchus

Total left Total left lung lung atelectasisatelectasis

Total left Total left lung lung atelectasisatelectasis

© S.T.A.B.L.E.®

© S.T.A.B.L.E.®

Chest Compressions/Ventilation

� 3:1 ratio of compressions to ventilations

� 90 compressions and 30 breaths = 120 events per minute120 events per minute

� Reassess every 30 seconds

� Discontinue resuscitation after 10 minutes of no heart beat and no respirations

TTemperature RegulationTTemperature Regulation

� Hypothermic infants

� How body heat is lost

� Detrimental effects of cold stress � Detrimental effects of cold stress

� Warming hypothermic and severely

hypothermic infants

Hypothermia

� Extremely vulnerable infants

include:

� Low birth weight

� Those requiring� Those requiring

prolonged

resuscitation

� Preventing cold

stress is a

challenge.© S.T.A.B.L.E.®

© S.T.A.B.L.E.®

Contact with cold or wet objectsContact with cold or wet objects

XX--rayray

Heat Loss by ConductionConductionConductionConduction

ScalesScales

XX--rayrayplatesplates

PrePre--warm scales warm scales and xand x--ray platesray plates

CautiouslyCautiously use use radiant heatradiant heat

Cover scale with Cover scale with warm blanketwarm blanket

© S.T.A.B.L.E.®

© S.T.A.B.L.E.®

Drafts and cold airDrafts and cold air

Heat Loss by ConvectionConvectionConvectionConvectionConvectionConvectionConvectionConvection

60 70 80 90

Move away from draftsMove away from drafts

Raise sides on warmerRaise sides on warmer

Close port holesClose port holes

Raise room temperatureRaise room temperature

© S.T.A.B.L.E.®

© S.T.A.B.L.E.®

Delivery, bathing, damp linensDelivery, bathing, damp linens

Dry thoroughlyDry thoroughly

Replace Replace wet linenswet linens

Heat Loss by EvaporationEvaporationEvaporationEvaporationEvaporationEvaporationEvaporationEvaporation

wet linenswet linens

CautiouslyCautiously use use radiant heatradiant heat

Do not bathe Do not bathe infant if infant if

showing signs showing signs of compromise of compromise

© S.T.A.B.L.E.®

© S.T.A.B.L.E.®

Cold windows and wallsCold windows and walls Use double walled Use double walled incubatorincubator

Use ISC Use ISC temperature probe temperature probe on radiant warmer on radiant warmer

(not manual)(not manual)

Heat Loss by RadiationRadiationRadiationRadiationRadiationRadiationRadiationRadiation

Move away from Move away from outside walls and outside walls and

windows windows

(not manual)(not manual)

© S.T.A.B.L.E.®

© S.T.A.B.L.E.®

Detrimental Effects of Cold

Stress

� Development of Metabolic Acidosis

caused by:

1. Brown fat metabolism causing

vasoconstrictionvasoconstriction

2. Decreased surfactant production

3. Increased anaerobic metabolism

4. Increased metabolic rate

FIGURE 31–6 Cold stress chain of events. The hypothermic, or cold-stressed,

newborn attempts to compensate by conserving heat and increasing heat production.

These physiologic compensatory mechanisms initiate a series of metabolic events

that result in hypoxemia and altered surfactant production, metabolic acidosis,

hypoglycemia, and hyperbilirubinemia.

Nursing Interventions to

Prevent Cold Stress

� Dry quickly — remove wet linens

� Use warm blankets

� Provide radiant warmer heat

� Place infant on ISC/servo control � Place infant on ISC/servo control

� Use heated, humidified O2 as soon as possible

� Remember: cold gas (O2) in, warm exhaled gases out

Guidelines for Re-warming

� Severely hypothermic infants —temperature < 35ºC (95ºF)

� Incubator

� Radiant warmer� Radiant warmer

� Core temperature goal — 37ºC (98.6ºF)

� While re-warming:

� Monitor vital signs constantly

� At risk for apnea, hypotension, RDS, metabolic acidosis, shock, death

© S.T.A.B.L.E.®

© S.T.A.B.L.E.®

AArtificial/Assisted BreathingAArtificial/Assisted Breathing

� Evaluating respiratory distress

� Indications for endotracheal intubation and

positive pressure ventilation

� Evaluating for pneumothorax, airway

obstruction

Respiratory distress is the most common Respiratory distress is the most common

reason for referral to an intensive care nurseryreason for referral to an intensive care nursery

Assessment & Monitoring

�� TemperatureTemperature

�� Heart rate and rhythm Heart rate and rhythm

�� Respiratory rate and effort Respiratory rate and effort

�� Blood pressureBlood pressure

�� OO22 saturationsaturation

�� OO2 2 concentrationconcentration

�� Skin perfusionSkin perfusion

�� Strength of pulses in arms and legsStrength of pulses in arms and legs© S.T.A.B.L.E.

®© S.T.A.B.L.E.

®

Diagnostic Tests to Perform

� Chest x-ray � If respiratory distress

� Abdominal x-ray

� If abdominal problem� If abdominal problem

� Blood gas

� Arterial or capillary

� CBC with differential

� Hematocrit

Respiratory Rate

� High rate: greater than 60 breaths per minute

� Low rate: less than 40 breaths per minute Low rate: less than 40 breaths per minute

� Shallow vs. labored

� Apnea

� Gasping

� Ominous pre-cardiac arrest sign!

Evaluate Respiratory Distress

� Retractions

� Mild, moderate, severe

� Intercostal, subcostal, substernal

� Nasal flaring present?

� Grunting

� Audible without a stethoscope?

Areas to Assess for Retractions

�� Substernal Substernal �� Substernal Substernal

�� SubcostalSubcostal�� SubcostalSubcostal

�� IntercostalIntercostal�� IntercostalIntercostal

�� SuprasternalSuprasternal�� SuprasternalSuprasternal

© S.T.A.B.L.E.®

© S.T.A.B.L.E.®

Evaluate Perfusion

� Capillary filling time — trunk and legs

� Strength of pulses

� Heart rate and rhythm

� Temperature of extremities

� Cyanosis and/or skin mottling

� Report color differences — upper versus lower body - Harlequin

Color and Oxygen Requirement

� Degree of cyanosis

� Peripheral versus central

� Amount of O2 to keep saturation > 88%2

� Rapidly increasing O2 concentration

� Arterial PO2 < 50 in more than 50% oxygen?

HCOHCO33 pHpH PCOPCO22

10

15

20

25

30

35

40

8.0

7.9

7.8

7.7

7.6

7.5

7.4

7.3

7.2

7.1

60

50

40

35

30

25

20

1540

50

60

70

80

90100110120130140150

7.1

7.0

6.9

6.8

6.7

6.6

10

9

8

7

6

4

3

© S.T.A.B.L.E.®

© S.T.A.B.L.E.®

HCOHCO33 pHpH PCOPCO22

10

15

20

25

30

35

40

8.0

7.9

7.8

7.7

7.6

7.5

7.4

7.3

7.2

7.1

60

50

40

35

30

25

20

15

MM

EE

TT

AA

BB

OO

L L

RR

EE

SS

P P

I I

RR

A A

TT

pH 7.4pH 7.4

PCOPCO22 3535

HCOHCO33 2222

POPO2 2 7575

© S.T.A.B.L.E.®

© S.T.A.B.L.E.®

40

50

60

70

80

90100110120130140150

7.1

7.0

6.9

6.8

6.7

6.6

10

9

8

7

6

4

3

L L

I I

CC

TT

OO

RR

YY

Is the pH normal? Is the pH normal?

Is the PCOIs the PCO22 normal? normal?

Is the HCOIs the HCO33 normal? normal?

Acidosis

� pH < 7.30 is abnormal

�� pH pH < 7.25< 7.25 is is concerningconcerning ——especially if in combination with poor especially if in combination with poor perfusion, tachycardia and/or low BPperfusion, tachycardia and/or low BPperfusion, tachycardia and/or low BPperfusion, tachycardia and/or low BP

�� pH pH < 7.20< 7.20 indicates indicates severe illnesssevere illnessand need for immediate interventionand need for immediate intervention

�� pH pH < 7.15< 7.15 indicates the infant is in indicates the infant is in severe crisissevere crisis

Causes of Respiratory Acidosis

Inadequate ventilation Inadequate ventilation →→→→→→→→ ↑↑↑↑↑↑↑↑ in in COCO22

� Lung disease

� Pneumonia, aspiration, RDS

� Pneumothorax� Pneumothorax

� Airway obstruction, Diaphragmatic Hernia

� Decreased respiratory drive

� Prematurity, apnea

� Neurologic impairment, asphyxia

Causes of Metabolic Acidosis

� Shock

� Poor perfusion

� Inadequate tissue oxygenation

↑↑↑↑↑↑↑↑ Lactic acid production Lactic acid production →→→→→→→→ ↓↓↓↓↓↓↓↓ in Hin HCOCO33

� Inadequate tissue oxygenation

� Cardiac disease - congenital heart defects

� Brain disorders – hemorrhage, meningitis

� Inborn errors of metabolism

Pneumothorax

� Sudden deterioration

�Bradycardia

�Cyanosis

�Signs of respiratory distress�Signs of respiratory distress

�� Evaluate forEvaluate for

�� Chest asymmetryChest asymmetry

�� Shift in point of maximum impulseShift in point of maximum impulse (PMI) (PMI)

�� Hypotension Hypotension

�� Poor peripheral pulsesPoor peripheral pulses

Note:Note:

ET tube in right ET tube in right mainstem mainstem bronchusbronchus

Note:Note:

ET tube in right ET tube in right mainstem mainstem bronchusbronchus

Pneumothorax Pneumothorax

bronchusbronchusbronchusbronchus

Right Right pneumothoraxpneumothoraxRight Right pneumothoraxpneumothorax

© S.T.A.B.L.E.®

2001

© S.T.A.B.L.E.®

2001

Right Right pneumothorax pneumothorax with left lung with left lung atelectasisatelectasis

Right Right pneumothorax pneumothorax with left lung with left lung atelectasisatelectasis

Pneumothorax Pneumothorax

�� UAC tip T6UAC tip T6--T7T7�� UAC tip T6UAC tip T6--T7T7

�� UVC tip T8UVC tip T8--T9T9�� UVC tip T8UVC tip T8--T9T9

�� ET tube T1ET tube T1�� ET tube T1ET tube T1

© S.T.A.B.L.E.®

© S.T.A.B.L.E.®

�� ET tube in ET tube in good positiongood position

�� ET tube in ET tube in good positiongood position

Pneumothorax Pneumothorax Pneumothorax Pneumothorax Pneumothorax Pneumothorax Pneumothorax Pneumothorax ���� SubpulmonicSubpulmonicSubpulmonicSubpulmonic���� SubpulmonicSubpulmonicSubpulmonicSubpulmonic

�� UAC tip T8UAC tip T8�� UAC tip T8UAC tip T8

�� UVC tip UVC tip right atriumright atrium

�� UVC tip UVC tip right atriumright atrium

© S.T.A.B.L.E.®

© S.T.A.B.L.E.®

Pneumothorax Pneumothorax Pneumothorax Pneumothorax Pneumothorax Pneumothorax Pneumothorax Pneumothorax ���� BilateralBilateralBilateralBilateral���� BilateralBilateralBilateralBilateral

© S.T.A.B.L.E.®

© S.T.A.B.L.E.®

Pneumothorax Pneumothorax Pneumothorax Pneumothorax Pneumothorax Pneumothorax Pneumothorax Pneumothorax ����Massive TensionMassive TensionMassive TensionMassive Tension����Massive TensionMassive TensionMassive TensionMassive Tension

Note:Note:

Mediastinal Mediastinal shiftshift

Note:Note:

Mediastinal Mediastinal shiftshift

© S.T.A.B.L.E.®

© S.T.A.B.L.E.®

shiftshiftshiftshift

Complete Complete right lung right lung collapsecollapse

Complete Complete right lung right lung collapsecollapse

Pneumopericardium

© S.T.A.B.L.E.®

© S.T.A.B.L.E.®

Airway Obstruction

� Main symptoms

� Stridor

� Retractions

� Airway obstruction may � Airway obstruction may occur at:

��NoseNose

��Mouth and jawMouth and jaw

��Larynx or trachea Larynx or trachea

��Bronchi Bronchi

Airway Obstruction

Choanal Atresia

�� Nasal obstructionNasal obstruction

�� Baby is cyanotic at restBaby is cyanotic at rest

�� “Pinks up” with crying “Pinks up” with crying

ChallengesChallengesChallengesChallengesChallengesChallengesChallengesChallenges

�� “Pinks up” with crying “Pinks up” with crying

�� If bilateral, may need oral airway or If bilateral, may need oral airway or endotracheal intubationendotracheal intubation

�� Oral airway sizes: Oral airway sizes:

�� 00 for small infants00 for small infants

�� 0 for term or large infants0 for term or large infants

Airway Obstruction Airway Obstruction Challenges Challenges -- PierrePierre--Robin SequenceRobin Sequence

Note small jawNote small jawNote small jawNote small jaw

Note cleft palateNote cleft palateNote cleft palateNote cleft palate

© S.T.A.B.L.E.®

© S.T.A.B.L.E.®

Intubation and PPV

Strongly consider intubation if:

�� Unable to or prolonged ventilation Unable to or prolonged ventilation and/or oxygenation with bag/mask and/or oxygenation with bag/mask ventilationventilation

�� Is cyanotic or marginally oxygenated in Is cyanotic or marginally oxygenated in 80% oxygen (O2 saturation < 88%)80% oxygen (O2 saturation < 88%)

�� PCOPCO22 is > 55, especially if pH < 7.25is > 55, especially if pH < 7.25

�� Diaphragmatic hernia, choanal atresia Diaphragmatic hernia, choanal atresia presentpresent

�� Apnea or gaspingApnea or gasping

© S.T.A.B.L.E.®

© S.T.A.B.L.E.®

Infants at Risk for Hypoglycemia

� SGA Small for gestational age

� LGA Large for gestational age

↓↓↓↓↓↓↓↓ Glycogen storesGlycogen stores↓↓↓↓↓↓↓↓ Glycogen storesGlycogen stores

HyperinsulinismHyperinsulinismHyperinsulinismHyperinsulinism

� IDM Infant of the diabetic mother

� Premature

� Stressed or sick

HyperinsulinismHyperinsulinismHyperinsulinismHyperinsulinism

↑↑↑↑↑↑↑↑ Glucose utilizationGlucose utilization↑↑↑↑↑↑↑↑ Glucose utilizationGlucose utilization

↓↓↓↓↓↓↓↓ Glycogen storesGlycogen stores↓↓↓↓↓↓↓↓ Glycogen storesGlycogen stores

© S.T.A.B.L.E.®

© S.T.A.B.L.E.®

Symptoms of Hypoglycemia

� Hypothermia

� Temperature instability

� Poor suck or refusal to eat

� Vomiting

� Cyanosis

�� JitterinessJitteriness

instability

� Lethargy, hypotonia

� Apnea, irregular respirations

� Cyanosis

� High-pitched or weak cry

� Seizures

Blood Glucose � Guidelines

� Avoid enteral feedings (PO or NG)

� Increased risk of aspiration w/ respiratory rate > 60 breaths per minute

• Gastroesophageal reflux

� Impaired bowel blood flow� Impaired bowel blood flow

• Necrotizing enterocolitis

� Establish IV access quickly to

� Normalize the blood sugar

� Provide emergency IV access

Blood Sugar Screening

� q 15-30 minutes until > 50 mg/dl (2.8mmol/L) on two consecutive tests

�� Perform frequently!Perform frequently!

�� If > 150 mg/dl (8.3 mmol/L) on two If > 150 mg/dl (8.3 mmol/L) on two consecutive tests consecutive tests —— seek consultationseek consultation

�� If (very) low obtain a serum blood sugar If (very) low obtain a serum blood sugar ��But don’t delay treatmentBut don’t delay treatment

Treatment

Initial blood sugar

< 50 (2.8 mmol/L)

�� Begin IV of Begin IV of DD W at 80 ml/kg/dayW at 80 ml/kg/day�� Begin IV of Begin IV of DD1010W at 80 ml/kg/dayW at 80 ml/kg/day

�� Repeat blood sugar within 30 minutes Repeat blood sugar within 30 minutes of first testof first test

�� Check blood sugar everyCheck blood sugar every 30 minutes 30 minutes until > 50 (2.8 mmol/L) on two until > 50 (2.8 mmol/L) on two consecutive testsconsecutive tests

Initial IV Fluid and Rate

� D10W without electrolytes

� 80 ml/kg/day

� Weight in kg multiplied by 80

� Then divide by 24 (hours)� Then divide by 24 (hours)

� Equals ml per hour to run the IV (via an infusion pump)

== ml/hrml/hrkg x 80

24

Treatment

Repeat blood sugar

< 50 (2.8 mmol/L)

after 1 hour of IV therapy

�� IncreaseIncrease the IV rate to the IV rate to 100 ml/kg/day100 ml/kg/day

�� Once > 50 (2.8 mmol/L) screen every Once > 50 (2.8 mmol/L) screen every 1 to 2 hours until transported or as 1 to 2 hours until transported or as needed based on patient’s conditionneeded based on patient’s condition

UAC low UAC low UAC low UAC low

UVC tip UVC tip in good in good

position at position at

UVC tip UVC tip in good in good

position at position at UAC low UAC low line line –– tip tip in good in good position position at L3at L3

UAC low UAC low line line –– tip tip in good in good position position at L3at L3

T12L1

2

3

4

L5

IVC/RA IVC/RA junctionjunctionIVC/RA IVC/RA junctionjunction

© S.T.A.B.L.E.®

© S.T.A.B.L.E.®

Umbilical Catheter Safety

� Use sterile technique

� Maintain an air-tight system

� Risk of significant blood loss with disconnection →disconnection →especially with UAC

� Tape securely

� Avoid thrombus

by adding heparin© S.T.A.B.L.E.

®© S.T.A.B.L.E.

®

FIGURE 30–4 Macrosomic infant of diabetic mother.

ScenarioS

29 week gestation infant precipitously delivers in

the birthing room

Assessment:

� Mottled skin — axillary temp 34°C (93.2°F)

Respiratory rate 80, grunting and retracting� Respiratory rate 80, grunting and retracting

� 80% O2 by hood oxygen

� Blood gas — PCO2 = 72

� Blood sugar 24 mg/dl (1.1 mmol/L)

� What is newborn’s problem(s)?

6 hours after delivery, term infant found to be 6 hours after delivery, term infant found to be dusky and tachypneic in mother’s roomdusky and tachypneic in mother’s room

ScenarioS

Assessment:

�Room air O2 saturation — 75%

Ashen skin color — axillary temp 35°C (95°F) �Ashen skin color — axillary temp 35°C (95°F)

�Respiratory rate — 70

�Capillary refill = 5 seconds — BP 40/20

� Initial blood gas pH 7.06 — consistent with severe metabolic acidosis

�What is newborn’s problem(s)?

NCLEX Question

� The nurse notes that at 5 minute after

birth, a neonate is pink with

acrocyanosis, has his knees flexed and

fists clenched, has a whimpering cry, has

a heart rate of 128 beats/minute, and a heart rate of 128 beats/minute, and

withdraws his foot to a slap on the sole.

What 5-minute Apgar score should the

nurse record for this neonate?

NCLEX Question� In the nursery, the nurse is performing a neurological

assessment on a 1-day-old neonate. Which findings would indicate possible asphyxia in utero? Select all that apply.

1. The neonate grasps the nurse’s finger when she puts it in the palm of his hand.the palm of his hand.

2. The neonate does stepping movements when held upright with his sole touching a surface.

3. The neonate’s toes don’t curl downward when the soles are stroked.

4. The neonate doesn’t respond when the nurse claps her hands above the baby.

5. The neonate turns toward an object when the nurse touches the cheek with it.

6. The neonate displays weak, ineffective sucking.

Thank you !Thank you !Thank you !Thank you !Thank you !Thank you !Thank you !Thank you !© S.T.A.B.L.E.

®© S.T.A.B.L.E.

®