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 cry; some flexion of extremities; responds to suctioning of the nares with respiration of 20; body pink in color with blue extremities.

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

A nurse is preparing to examine a post-term newborn immediately following delivery. Which of the following findings should she expect to observe? (Select all that apply.) The correct answers are choices C and E: Cracked, peeling skin and Vernix in the folds and creases.

Choice A rationale:

The Moro reflex is a normal neonatal reflex that can be observed in newborns at term or preterm, not specifically in post-term newborns. It is characterized by the baby's response to a sudden loss of support, which causes them to startle, throw their arms out, and cry. This reflex is not unique to post-term newborns.

Choice B rationale:

The heel to ear maneuverability is not a typical finding in newborn assessments. It is not related to the term or post-term status of the newborn. Therefore, this choice is not applicable.

Choice C rationale:

Cracked, peeling skin is a common finding in post-term newborns. Post-term babies have been in the womb for a longer duration, which can lead to changes in the condition of their skin, including peeling and cracking. This is due to prolonged exposure to amniotic fluid and the protective vernix diminishing.

Choice D rationale:

Abundant lanugo is more commonly found in preterm or premature newborns. As babies approach their due date and beyond, they tend to shed this fine, downy hair. Therefore, this choice is not applicable to post-term newborns.

Choice E rationale:

Vernix in the folds and creases is a characteristic finding in post-term newborns. Vernix is a white, waxy substance that coats the skin of newborns. In post-term babies, this vernix may be found in the folds and creases of their skin, as they have had more time in the womb for it to accumulate.

Choice A rationale:

Copious vaginal bleeding Rationale: Copious vaginal bleeding, especially if it's heavy and associated with pain, can be a sign of a miscarriage or other significant complications during pregnancy. While some bleeding can be normal in early pregnancy (implantation bleeding), copious bleeding is not expected and should prompt immediate medical attention. However, it is not a typical finding for an ectopic pregnancy.

Choice B rationale:

Pelvic pain Rationale: Pelvic pain is a concerning symptom in a client with a possible ectopic pregnancy. Ectopic pregnancies occur when the fertilized egg implants outside the uterus, often in the fallopian tube. As the embryo grows, it can cause the tube to rupture, leading to severe abdominal pain and internal bleeding. Pelvic pain is a hallmark symptom of an ectopic pregnancy and should be reported to the provider immediately.

Choice C rationale:

Uterine enlargement greater than expected for gestational age Rationale: Uterine enlargement is expected during pregnancy as the uterus accommodates the growing fetus. However, in the case of an ectopic pregnancy, the fertilized egg implants outside the uterus, typically in the fallopian tube. Therefore, uterine enlargement greater than expected for gestational age would not be a typical finding. This choice is not correct for an ectopic pregnancy.

Choice D rationale:

Severe nausea and vomiting Rationale: Severe nausea and vomiting can be associated with pregnancy-related conditions like hyperemesis gravidarum, but it is not a typical finding in ectopic pregnancies. Ectopic pregnancies are more likely to present with pelvic pain and may progress to severe abdominal pain if the fallopian tube ruptures. .