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?

Monitor for signs of jaundice.A cephalohematoma is a collection of blood under the scalp that occurs due to trauma or pressure during delivery.It may increase the risk of jaundice in the newborn due to the breakdown of red blood cells and the release of bilirubin.Jaundice is a condition that causes yellowing of the skin and eyes due to high levels of bilirubin in the blood.Monitoring for signs of jaundice is important to prevent complications such as brain damage or kernicterus.

Apply pressure dressing over the area.This is wrong because applying pressure may increase the bleeding and cause more damage to the scalp and skull.A cephalohematoma does not require any treatment and usually resolves on its own within weeks or months.

Administer antibiotics as prescribed.This is wrong because antibiotics are not indicated for a cephalohematoma unless there is evidence of infection.Infection is a rare complication that may lead to osteomyelitis or meningitis.Antibiotics should be used only if prescribed by a doctor based on clinical signs and laboratory tests.

Elevate the head of the bed.This is wrong because elevating the head of the bed may not have any effect on a cephalohematoma.It may also cause discomfort or compromise the airway of the newborn.The position of the baby should be adjusted according to their comfort and safety.

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.