A nurse performs an initial assessment on a neonate. The neonate has a heart rate of 130 beats/minute and is gasping for air. The neonate has blue extremities and is moving vigorously. When stimulated, the infant only grimaces. What should the nurse do next?

Assign an Apgar of 7, place the patient in modified Trendelenburg, and apply oxygen.

Explanation

• The patient's Apgar score is 7. The patient is in respiratory distress and is having trouble oxygenating her extremities. Placing the patient in modified Trendelenburg will ensure adequate blood flow to her brain and vital organs.

Heart rate of 130 beats/minute: 2 pts 

Gasping for air: 1 pt

Blue extremities: 1 pt

Moving vigorously: 2 pts

When stimulated, the neonate only grimaces: 1 pt

• The patient does not need resuscitation.

Apgar scored from 0 to 10. Each category is scored 0 to 2.

• Appearance: Blue/pale all over, blue extremities/pink body, entire body pink
• Pulse: Absent, <100, >100
• Grimace: No response to stimulation, grimace/feeble cry, cry or pull away
• Activity: None, some flexion, flexed extremities that resist extension
• Respiration: Absent, weak/irregular/gasping, strong cry

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