A nurse is assisting in the care of a newborn following birth. At 1 min after birth, the nurse notes the following: heart rate 110/min; slow, weak cord flexion of extremities; grimace in response to suctioning of the nares; body pink in color with blue extremities.

What should the nurse document as the newborn's 1-min Apgar score?

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Determine the client’s temperature. This is because shaking chills during the immediate postpartum period can be a sign of infection, such as endometritis or mastitis. Infection is a serious complication that can lead to sepsis and shock if not treated promptly. The nurse should measure the client’s temperature and look for other signs of infection, such as foul-smelling lochia, breast tenderness, or tachycardia.

Choice A is wrong because placing the client on seizure precautions is not indicated for shaking chills. Seizure precautions are used for clients who have eclampsia or other conditions that increase the risk of seizures.

Choice B is wrong because covering the client with warm blankets may not be helpful for shaking chills. Warm blankets may increase the body temperature and worsen the infection.

Choice C is wrong because notifying the charge nurse is not the first action the nurse should take. The nurse should assess the client’s condition before reporting to the charge nurse or the provider.

Sternal or chest retractions. This is because sternal or chest retractions are a sign of respiratory distress in newborns, which means they are having difficulty breathing. Chest retractions occur when the baby's chest pulls in with each breath, indicating that they are using extra muscles to breathe. This can be caused by various conditions that affect the lungs, such as respiratory distress syndrome (RDS), transient tachypnea of the newborn (TTN), meconium aspiration syndrome (MAS), pneumonia, or congenital heart defects.

Choice A is not correct because mucus draining from the nose is not a symptom of respiratory distress in newborns. It is normal for newborns to have some mucus in their nose and mouth after birth, which can be cleared by suctioning or wiping.

Mucus drainage does not interfere with breathing unless it is excessive or thick.

Choice B is not correct because cyanosis of the hands and feet is not a symptom of respiratory distress in newborns. It is normal for newborns to have bluish discoloration of their hands and feet, called acrocyanosis, for the first few days after birth. This is due to immature circulation and does not indicate a lack of oxygen. Cyanosis of the central parts of the body, such as the face, lips, and tongue, is more concerning and should be reported.

Choice C is not correct because irregular heart rate is not a symptom of respiratory distress in newborns. It is normal for newborns to have some variations in their heart rate, especially during sleep cycles. The normal heart rate range for newborns is 100 to 160 beats per minute. A heart rate that is too fast (tachycardia) or too slow (bradycardia) may indicate a problem with the heart or other organs³.