A vaginal exam reveals that Cindy is 10cms, 100% effaced and the fetus is at a +

Question

A vaginal exam reveals that Cindy is 10cms, 100% effaced and the fetus is at a +3 station.

What actions do you as the nurse need to take?

What preparations need to be made for the anticipated delivery?

Cindy delivered a 7lb 4oz baby girl. Initial assessment of the infant reveals the following: Heart rate Respiratory rate Muscle tone Reflex irritability Color 125 Slow, weak cry Some flexion Cry Body pink, extremities blue

Determine the 1 minute Apgar score based on the above information.

What actions should you as the nurse take?

What factors may have influenced the infant having a slow weak cry and only some flexion of the extremities?

Explanation / Answer

The nurse plays a crucial role before, during and after the delivery. women feel precious and at the same time threatened to the delivery. The nurse has to provide comfort and to give information about the delivery. Support the Cindy emotionally.

Preparation for the anticipated Delivery:

Apgar scoring:

Appearance

(skin colour)

1

Skin colour is pink but the extremities are bluish.

2

Normal above 100 beats per rate.

Grimace response (reflexes)

1

weak cry.

1

Some flexion

1

Slow, weak cry.

The total Apgar scoring is 6. The baby needs some immediate response to clearing the airway and supplemental oxygen. Place the newborn warm. Repeat the Apgar score after 5 minutes. Usually, after the 5-minute score has greater predictive value.

The factors influencing weak, slow cry, and some flexion of extremities are varied due to many reasons, but the common factors are prematurity, trauma, obstetrical issues, maternal medication, and congenital issues. Usually, thermoregulation, supportive care, and observation are needed in the newborn.

1.

Appearance

(skin colour)

1

Skin colour is pink but the extremities are bluish.

2. Pulse Rate (Heart Rate)

2

Normal above 100 beats per rate.

3.

Grimace response (reflexes)

1

weak cry.

4. Activity (muscle Tone)

1

Some flexion

5. Respiration (breathing rate and effort)

1

Slow, weak cry.

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