Page 811 - Saunders Comprehensive Review For NCLEX-RN

safety procedures.
9. Place matching identification bracelets on the mother
and the newborn.
C. Apgar scoring system
1. Assess each of 5 items to be scored and add the points
to determine the newborn’s total score.
2. Five vital indicators (Table 27-1)
3. Interventions: Apgar score (Table 27-2)

The newborn’s Apgar score is routinely assessed and

recorded at 1 minute and 5 minutes after birth, and may be repeated
later if the score is and remains low.
II. Initial Physical Examination

A. General guidelines
1. Keep the newborn warm during the

examination.
2. Begin with general observations, and then

perform assessments that are least disturbing to the
newborn first.
3. Initiate nursing interventions for abnormal findings
and document findings.
4. The Ballard Scale may be used for gestational age
assessment; in this scale, scores are assigned to
physical and neurological criteria.

The phases of newborn instability occur during the first 6 to 8

hours after birth and are known as the transition period between
intrauterine and extrauterine existence. These phases include the first
period of reactivity, period of decreased responsiveness, and second
period of reactivity.
B. Vital signs

1. Heart rate (resting): 110 to 160 beats per

minute (apical), 90 to 110 beats per minute (if
sleeping), up to 180 beats per minute (if crying);
auscultate at the fourth intercostal space for 1 full
minute to detect abnormalities.
2. Respirations: 30 to 60 breaths per minute; assess for 1
full minute.
3. Assess heart rate and respiratory rate first before
assessing other vital signs while the newborn is

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