A nurse is preparing to administer erythromycin ointment to a newborn’s eyes as prophylaxis for gonorrhea and chlamydia infections.

Which of the following actions should the nurse take?

Normal finding.

The anterior fontanelle is the soft spot on the top of an infant’s head that allows for brain growth and skull expansion.

It normally feels soft and flat when the infant is lying down, and may bulge slightly when the infant is sitting up or crying due to increased blood flow and pressure.

This is not a sign of any problem and should be documented as a normal finding.

Dehydration is wrong because dehydration would cause the fontanelle to feel sunken or depressed, not elevated. Dehydration can also cause other signs such as dry mouth, decreased urine output, and lethargy.

Increased intracranial pressure is wrong because increased intracranial pressure would cause the fontanelle to feel tense or bulging at all times, not only when sitting up or crying. Increased intracranial pressure can also cause other signs such as vomiting, irritability, seizures, and altered level of consciousness.

Infection is wrong because infection would cause the fontanelle to feel warm or tender, not elevated. Infection can also cause other signs such as fever, rash, poor feeding, and fussiness.

Based on the Apgar score components provided, the newborn would likely receive the following scores:

• Appearance (color):Pink all over -2 points
• Pulse (heart rate):120 bpm -2 points
• Grimace (reflex irritability):Makes a strong cry -2 points
• Activity (muscle tone):Active movement -2 points
• Respiration:Deep, regular breaths -2 points

Adding these together, the newborn’s Apgar score would be10, which indicates the baby is in excellent condition following delivery.

The Apgar score is a quick assessment method used to evaluate a newborn baby’s health immediately after birth and again 5 minutes later. It was created by Dr. Virginia Apgar in 1952 and is an important tool for healthcare professionals to determine the immediate physical condition of a newborn and the need for any urgent medical care.

Here’s what the Apgar score measures, with each category receiving a score from 0 to 2:

• Appearance (color):Checks the baby’s skin tone
• Pulse (heart rate):Measures the heart rate
• Grimace (reflex irritability):Assesses the reflex response
• Activity (muscle tone):Evaluates muscle tone and movement
• Respiration:Observes the breathing effort and regularity

The significance of the Apgar score lies in its ability to provide a standardized and rapid assessment of a newborn’s vital signs and immediate health. It helps to quickly identify babies who are struggling and may need additional medical attention.However, it’s important to note that the Apgar score is not designed to predict long-term health outcomes or neurological development.It’s one of many assessments used to understand a baby’s condition at birth.

Here’s a table that outlines the Apgar score criteria and the points assigned for each:

Table

The Apgar score is calculated at 1 minute and 5 minutes after birth. Each of the five criteria is scored between 0 and 2, with a maximum total score of 10. This scoring system helps medical professionals quickly assess the newborn’s general condition and determine if any immediate medical intervention is needed. A score of 7 to 10 is considered normal, 4 to 6 fairly low, and 3 and below critically low.