A nurse is caring for a newborn. How many blood vessels should the nurse expect to observe in the newborn's umbilical cord?

The correct answers are choices A. Blood pressure, B. Cerebral manifestations, and E. Deep tendon reflexes.

Choice A rationale:

Blood pressure is a critical parameter to monitor, especially in the third trimester. Elevated blood pressure can indicate preeclampsia, a serious condition that requires immediate attention.

Choice B rationale:

Cerebral manifestations, such as headaches or visual disturbances, can also be signs of preeclampsia. These symptoms should be reported to the provider immediately.

Choice C rationale:

The fetal heart rate of 158/min is within the normal range (110-160 beats per minute) and does not need to be reported.

Choice D rationale:

The respiratory rate is not mentioned in the provided notes, and there is no indication that it is abnormal. Therefore, it does not need to be reported.

Choice E rationale:

Deep tendon reflexes that are hyperactive (3+) can be a sign of preeclampsia. This finding should be reported to the provider.

Choice A rationale:

Stimulate the infant to cry. While stimulating the infant to cry is a common practice to assess the newborn's respiratory function, it is not the first action the nurse should perform in this situation. The newborn may cry spontaneously or may require other interventions, such as clearing the respiratory tract, before crying.

Choice B rationale:

Clear the respiratory tract. Clearing the respiratory tract is the priority action in this scenario. It ensures that the airway is open and allows the infant to breathe effectively. This is crucial because newborns are at higher risk of respiratory distress after birth, and prompt action can prevent complications.

Choice C rationale:

Dry the infant off and cover the head. Drying the infant off and covering the head are important steps to prevent heat loss and maintain the newborn's body temperature. However, these actions can be delayed briefly until the respiratory tract is cleared, as the immediate focus should be on ensuring the infant's ability to breathe.

Choice D rationale:

Clamp the umbilical cord. Clamping the umbilical cord is a standard procedure after birth to prevent bleeding and infection. However, it is not the priority in this situation. The first step should be to ensure the newborn's airway is clear and they can breathe adequately.