Exhibits

Based on the FLACC score and the client's developmental level, mark which nurse actions would be appropriate, and which would not be appropriate. Each row must have one option selected.

A. Heat loss. Newborns are highly susceptible to heat loss due to their large surface area relative to body weight and limited ability to generate heat. Cold stress can lead to hypoglycemia, respiratory distress, and metabolic acidosis. To prevent this, the nurse should dry the newborn thoroughly, provide skin-to-skin contact, and use a radiant warmer or warm blankets immediately after birth.
B. Fluid balance. While newborns require close monitoring of fluid balance, they are born with sufficient fluid stores. Dehydration is not an immediate concern within the first few minutes of life. Initial interventions focus on thermoregulation and establishing respiration.
C. Bleeding tendencies. Newborns have low vitamin K levels, which increase the risk of bleeding. However, vitamin K prophylaxis is given within the first hour after birth and is not the immediate priority over establishing adequate oxygenation and thermoregulation.
D. Hypoglycemia. Hypoglycemia is a concern, especially in infants of diabetic mothers or those with low birth weight. However, preventing heat loss is a higher priority, as cold stress can contribute to hypoglycemia. Once thermoregulation is established, glucose monitoring can be performed as needed.

A. Hepatitis B immunoglobulin. Hepatitis B immunoglobulin (HBIG) is administered to newborns whose mothers are hepatitis B surface antigen (HBsAg) positive to provide passive immunity. Since the client’s hepatitis B status is negative, there is no need for HBIG administration to the newborn.
B. Rubella vaccination. The client is rubella non-immune, meaning they are susceptible to rubella infection, which can cause congenital defects in future pregnancies. The rubella vaccine is a live attenuated virus and is contraindicated during pregnancy but should be administered postpartum before discharge to ensure immunity before the next pregnancy. Breastfeeding is not a contraindication to vaccination.
C. Blood transfusion. The client's hemoglobin (12.5 g/dL) and hematocrit (34%) are within the normal range for postpartum values, indicating that a blood transfusion is not necessary. Blood transfusions are reserved for clients with severe anemia (hemoglobin below 7 g/dL) or significant postpartum hemorrhage.
D. Penicillin G potassium. Group B Streptococcus (GBS) positive status is relevant during labor and delivery, requiring intrapartum antibiotic prophylaxis to prevent neonatal sepsis. Since delivery has already occurred, there is no need for Penicillin G at this time unless there are signs of an active infection in the mother or newborn.