A full term newborn was just born. Which nursing intervention is important for the nurse to perform first?

A) Bacteria that synthesize vitamin K are not present in the newborn's intestinal tract:
Newborns are born with a sterile gastrointestinal tract, meaning they do not yet have the intestinal bacteria necessary to synthesize vitamin K. Vitamin K is essential for the activation of clotting factors, and without sufficient vitamin K, newborns are at risk for bleeding disorders, particularly a condition known as vitamin K deficiency bleeding (VKDB). Administering vitamin K by injection shortly after birth ensures the baby has adequate levels to prevent bleeding.
B) Vitamin K prevents the synthesis of prothrombin in the liver and must be given by injection:
This statement is incorrect. Vitamin K does not prevent the synthesis of prothrombin; rather, it is essential for the liver to synthesize clotting factors, including prothrombin. The injection of vitamin K in newborns is necessary to provide adequate levels of vitamin K to support proper blood clotting, as newborns cannot produce enough on their own at birth due to the absence of gut bacteria that normally produce it.

C) The supply of vitamin K is inadequate for at least 12 months, and the newborn must be supplemented throughout infancy:
While it is true that newborns have a limited supply of vitamin K at birth, this deficiency is typically addressed with a single injection given shortly after birth. Supplementing vitamin K throughout infancy is generally not required, as the infant's gastrointestinal tract will start to develop the necessary bacteria to synthesize vitamin K within the first few weeks to months of life. The first dose of vitamin K prevents bleeding disorders, and in most cases, additional supplementation is not necessary.

D) Most mothers have a diet deficient in vitamin K, which results in the infant being deficient:
While maternal diet does play a role in the newborn's initial vitamin K levels, it is not the primary reason for the deficiency. Vitamin K deficiency in newborns is primarily due to the lack of gut bacteria necessary to produce it, rather than maternal diet. The practice of administering vitamin K to all newborns ensures that they receive adequate levels to prevent bleeding, regardless of maternal dietary intake.

A) Pauses in respiration lasting 30 seconds:
Pauses lasting longer than 20 seconds or accompanied by other signs of distress would warrant further evaluation. A 30-second pause by itself, without additional concerning symptoms, is generally not a reason for immediate action.

B) Respiratory rate 36, crackles present bilaterally:
The presence of bilateral crackles is concerning. Crackles can indicate fluid in the lungs, possibly from retained amniotic fluid or respiratory distress syndrome (RDS). In a term newborn, bilateral crackles at this time, especially if accompanied by tachypnea or other signs of respiratory distress, may indicate a serious respiratory issue, such as aspiration pneumonia or RDS. Immediate assessment and intervention are necessary to ensure the infant is breathing adequately and that there are no underlying complications.

C) Apical heart rate of 160 with mild systolic murmur heard:
An apical heart rate of 160 is within the normal range for a newborn (typically 120-160 bpm). A mild systolic murmur is also not uncommon in newborns and may be benign, especially in the first few days of life. Murmurs are often transient and can be caused by normal circulatory changes as the newborn's cardiovascular system adjusts after birth. Although a heart murmur should be monitored, it is not typically an urgent concern unless associated with signs of poor perfusion or other cardiac symptoms.

D) Small white papules on nose and chin:
These small white papules are likely milia, which are common and harmless in newborns. Milia are keratin-filled cysts that typically appear on the face, especially around the nose and chin. They are a normal finding and resolve on their own without treatment. These papules do not require immediate action.