A nurse is admitting a client who is at 39 weeks of gestation and who states, "My water broke on the way to the hospital." Which of the following actions should the nurse take first?

A. Supplement feedings with dextrose water – Dextrose water is not appropriate for newborn feeding. It lacks the necessary calories and nutrients and is not recommended for managing hyperbilirubinemia or hydration.

B. Administer intravenous dextrose – There is no evidence of hypoglycemia or need for IV fluids. This is not indicated based on the current assessment.

C. Obtain a total serum bilirubin – The yellow sclera and cephalohematoma (from vacuum-assisted birth) place the newborn at risk for hyperbilirubinemia. A serum bilirubin level is needed to assess severity.

D. Encourage breastfeeding every 2 hr – This promotes bilirubin excretion through stools and urine, which is essential in managing or preventing jaundice in newborns.

E. Prepare for an exchange transfusion – This is a treatment for severe hyperbilirubinemia or hemolytic disease, and is not indicated at this stage without bilirubin results.

F. Obtain blood cultures – The mother received appropriate intrapartum prophylaxis (2 doses of penicillin G) for GBS. The newborn shows no signs of sepsis (vital signs normal, active, feeding), so cultures are not indicated now.

A. An amniotic fluid index of 1 cm is abnormally low (oligohydramnios) and indicates potential fetal compromise, so this finding does not reflect fetal well-being.

B. Fetal limb movements are an important indicator of fetal activity and neurological function. Observing four or more discrete limb movements in 30 minutes meets one of the criteria for a reassuring biophysical profile, suggesting the fetus is active and neurologically intact.

C. A nonreactive nonstress test indicates the fetus is not showing adequate heart rate accelerations in response to movement, which can signal potential hypoxia or fetal compromise.

D. Sustained fetal breathing movements of 20 seconds in 30 minutes are desirable, but the minimum standard for the BPP is usually one or more episodes of 30 seconds within 30 minutes; 20 seconds alone may not meet the threshold, making limb movements a more reliable indicator in this scenario.