A woman gave birth to a 7-lb, 3-ounce infant boy 2 hours ago. The nurse determines that the woman's bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. In the immediate after birth period, the most serious consequence likely to occur from bladder distention is:

The Apgar score is calculated based on five criteria, each scored from 0 to 2:

1. Heart rate

   • 0 = Absent
   • 1 = Below 100 beats per minute ✅
   • 2 = 100 or more beats per minute

2. Respiratory effort

   • 0 = Absent
   • 1 = Slow, irregular ✅
   • 2 = Good, crying

3. Muscle tone

   • 0 = Limp
   • 1 = Some flexion of extremities ✅
   • 2 = Active motion

4. Reflex irritability (response to stimulation, e.g., suctioning)

   • 0 = No response
   • 1 = Grimace ✅
   • 2 = Crying, active withdrawal

5. Color

   • 0 = Blue, pale
   • 1 = Body pink, extremities blue
   • 2 = Completely pink

Apgar Score Calculation:

• Heart rate: 1
• Respiratory effort: 1
• Muscle tone: 1
• Reflex irritability: 1
• Color: 0

Total Apgar Score: 4

A score of 4 suggests the newborn is in distress and requires immediate medical intervention, such as oxygen support and further assessment.

A) It could make respiratory distress syndrome worse:
The most critical reason to protect a preterm infant from cold stress is that hypothermia can exacerbate respiratory distress syndrome (RDS). Cold stress leads to an increased oxygen demand, which can worsen the infant’s already compromised respiratory function. In preterm infants, the immature lungs and underdeveloped surfactant production contribute to RDS, and hypothermia worsens the situation by increasing metabolic demands and impairing pulmonary function. Maintaining a stable body temperature is crucial for minimizing respiratory complications.

B) Shivering to produce heat may use up too many calories:
While it is true that preterm infants may not have the metabolic reserves to generate heat via shivering (as they lack significant brown fat), the primary concern is not shivering. Preterm infants generally do not shiver, and cold stress does not trigger this response. Instead, their body tries to conserve heat through vasoconstriction and increased metabolism, which can lead to hypoxia and worsening respiratory distress.

C) A low temperature may make the infant less able to digest nutrients:
Cold stress can affect a preterm infant’s gastrointestinal function by reducing blood flow to the digestive organs, which can impair nutrient absorption and digestion. However, the most immediate and serious consequence of cold stress is the increased metabolic demand and worsening of respiratory distress, rather than a direct impact on digestion. Protecting the infant from hypothermia helps prevent these secondary complications.

D) Cold decreases circulation to the extremities:
While cold stress can indeed lead to vasoconstriction and decreased circulation to the extremities, this is not the most significant concern. The primary issue with cold stress in preterm infants is the overall increase in metabolic demands, oxygen consumption, and exacerbation of respiratory problems, which can lead to more severe respiratory distress syndrome. The loss of peripheral circulation is a secondary concern.