At 1 minute after birth the nurse assesses the newborn and notes the following:

Heart rate: 80 beats/minute

Respiratory effort: slow, irregular

Muscle tone: some flexion of extremities

Reflex irritability: grimacing

Color: blue and pale

The nurse would calculate an Apgar score of:

A) Caput succedaneum present:
Caput succedaneum refers to the swelling of the soft tissues on the newborn's head, typically caused by the pressure exerted during vaginal delivery. This condition is often seen after a prolonged labor or in cases of vacuum-assisted delivery. It presents as a soft, fluid-filled swelling that crosses the suture lines, which distinguishes it from a cephalhematoma (a collection of blood). This swelling is usually benign and resolves within a few days after birth without intervention.

B) Severe molding present:
Molding refers to the shaping of the newborn's skull bones as they overlap to pass through the birth canal during delivery. It typically presents as elongated or asymmetric head shapes, particularly in the vertex presentation. Severe molding would not involve swelling of the soft tissues and would not cross the suture lines. This term is typically used to describe changes in the shape of the skull bones rather than soft tissue swelling.

C) Cephalhematoma present:
A cephalhematoma is a collection of blood between the newborn's skull and the periosteum (the membrane covering the bones). Unlike caput succedaneum, a cephalhematoma does not cross the suture lines because the blood is confined to the area overlying the affected bone. Cephalhematomas are typically the result of trauma during delivery, such as forceps or vacuum extraction. The swelling in a cephalhematoma is firmer and does not appear as soft or fluid-filled as caput succedaneum.

D) Fontanels soft and flat:
The fontanels are the soft spots on the baby’s head where the skull bones have not yet fused. The anterior fontanel is usually the most prominent, and the posterior fontanel is much smaller. While fontanels should be soft and flat in the early stages, this option doesn't describe the swelling or soft tissue findings as described in the question. The soft, fluid-filled swelling over the head would be more indicative of caput succedaneum rather than a normal fontanel finding.

A) Clear fluids from airway:
Immediately clearing the infant's airway is one of the first steps in stabilizing the newborn after birth. This ensures the infant can breathe freely, reducing the risk of aspiration or airway obstruction. Suctioning the mouth and nose with a bulb syringe or suction catheter is the usual practice, especially if there are visible fluids or secretions. This intervention is critical for ensuring the infant's respiratory function.

B) Immediately assess and bathe baby:
While assessing the newborn is vital, it is not the immediate priority. The first step in stabilization is ensuring the newborn’s airway is clear, followed by efforts to prevent heat loss. Bathing should be delayed until after the baby is stable, and drying the baby thoroughly should be done as the first action to prevent hypothermia.

C) Dry infant thoroughly:
Drying the newborn thoroughly after birth is essential for preventing heat loss. Wet skin can quickly lead to hypothermia, and drying helps maintain the infant's body temperature. This intervention is vital for stabilizing the newborn and ensuring thermoregulation in the first moments of life.

D) Place baby skin to skin:
Skin-to-skin contact is a fundamental practice immediately after birth. It promotes bonding, helps regulate the infant's temperature, supports successful breastfeeding initiation, and stabilizes vital signs like heart rate and blood sugar levels. The mother’s body heat helps the baby maintain a normal temperature, which is especially important right after birth.

E) Give erythromycin ointment in baby’s eyes:
While applying erythromycin ointment to the baby’s eyes is a standard practice to prevent neonatal conjunctivitis (especially from gonorrhea or chlamydia), it is not a priority for immediate stabilization. This step is typically performed later, after the newborn is stable, and thermoregulation is addressed. The primary focus should be on airway clearance, drying, and promoting skin-to-skin contact first.