A nurse is caring for a newborn and calculating the Apgar score. At 1 min after delivery, the following findings are noted: heart rate of 110/min; slow, weak cry, some flexion of extremities; grimace in response to suctioning of the nares; body pink in color with blue extremities.

Calculate the newborn's Apgar score.

Rationale:

A. "Your baby should sleep at least 6 hours between feedings.": Newborns typically wake every 2-3 hours for feeding, so sleeping for 6 hours between feedings is not indicative of adequate breastfeeding.

B. "Your baby should burp after each feeding.": Burping is important for gas relief but does not necessarily indicate sufficient breastfeeding.

C. "Your baby should have a wake cycle of 30 to 60 minutes after each feeding.": The wake cycle after feeding is not a reliable indicator of sufficient breastfeeding.

D. "Your baby should wet 6 to 8 diapers per day.": Monitoring the number of wet diapers is a

reliable indicator of adequate breastfeeding. A newborn who is getting enough breast milk should produce at least 6 to 8 wet diapers per day, indicating sufficient hydration and nutrient intake.

Rationale:

A. Obtain a type and crossmatch: While obtaining a type and crossmatch may be necessary in the event of significant hemorrhage, the first action should be to address the potential cause of hypotension, which could be uterine atony.

B. Evaluate the firmness of the uterus: Postpartum hypotension is often caused by uterine atony, so the first action should be to assess the firmness of the uterus and massage it to stimulate contraction if necessary.

C. Administer oxytocin infusion: Oxytocin infusion may be necessary to help contract the uterus and control bleeding, but it should be implemented after assessing uterine firmness.

D. Initiate oxygen therapy by nonrebreather mask: While oxygen therapy may be needed if the client is hypotensive due to hemorrhage, assessing uterine firmness is the priority action to address the potential cause of hypotension.