An infant's axillary temperature is 35.9C (96.6F). The priority nursing action is to:

The correct answer is choice D. Announcement of the delivery.

Choice A reason:

Support thermoregulation is a priority in nursing care of the newborn immediately after birth. Newborns are at risk of hypothermia because they have a large surface area to body mass ratio, thin skin, and limited subcutaneous fat. To prevent heat loss, newborns should be dried thoroughly, placed skin-to-skin with the mother, and covered with warm blankets.

Choice B reason:

Identifying the infant is a priority nursing care of the newborn immediately after birth. Newborns should be identified with identification bands that match those of the mother and father or significant other. This helps prevent errors in infant identification and ensures safety and security.

Choice C reason:

Promoting normal respirations is a priority nursing care of the newborn immediately after birth. Newborns need to establish effective breathing patterns to ensure adequate oxygenation and prevent complications such as respiratory distress syndrome or meconium aspiration syndrome. To promote normal respirations, newborns should be suctioned gently to clear the airway, stimulated to cry, and assessed for signs of distress.

Choice D reason:

Announcement of the delivery is not a priority in nursing care of the newborn immediately after birth. While it may be a joyful moment for the parents and family, it does not affect the health and well-being of the newborn. Therefore, it can be done later after the essential newborn care has been completed.

The correct answer is c. Dehydration. A significantly indented anterior fontanelle in a newborn is most commonly a sign of dehydration.

Choice A reason:

Increased intracranial pressure: This statement is incorrect because increased intracranial pressure typically causes a bulging, not indented, fontanelle. Symptoms include irritability, vomiting, and a high-pitched cry.

Choice B reason:

Vernix caseosa: This statement is incorrect because vernix caseosa is a white, cheesy substance covering the skin of newborns, unrelated to fontanelle indentation. It serves as a protective layer for the baby’s skin.

Choice C reason:

Dehydration: This statement is correct. Dehydration in newborns can cause a sunken fontanelle due to the loss of fluid. Other signs include dry mouth, sunken eyes, and fewer wet diapers.

Choice D reason:

Cyanosis: This statement is incorrect because cyanosis refers to a bluish discoloration of the skin due to lack of oxygen, not related to fontanelle shape. It indicates issues with oxygenation or circulation.