Exhibits

Question 2(B) Complete the following sentence by using the lists of options. The nurse should first

dropdown

before performing a heel stick, followed by

dropdown

.

Choice A rationale

A respiratory rate (RR) of 24/min in a 4-hour-old newborn is below the normal range, which is typically 30 to 60 breaths per minute. A sustained low respiratory rate, especially in a neonate, can indicate respiratory depression, central nervous system depression, or impending respiratory failure, necessitating immediate reporting to the healthcare provider for further evaluation and intervention to ensure adequate oxygenation and ventilation.

Choice B rationale

A blood pressure (BP) of 82/44 mm Hg is generally within the expected normal range for a full-term newborn, with typical systolic values ranging from 60 to 90 mm Hg and diastolic values from 30 to 60 mm Hg. This finding reflects adequate cardiac output and vascular tone; therefore, it is considered a reassuring and expected physiological finding that does not require immediate notification of the provider.

Choice C rationale

A temperature of 37.2° C (99° F) falls within the normal range for a newborn, which is typically between 36.5° C and 37.5° C (97.7° F and 99.5° F). This temperature indicates effective thermoregulation and is an expected finding, as newborns maintain a slightly higher core temperature than older children and adults.

Choice D rationale

A heart rate (HR) of 150/min is within the normal resting heart rate range for a newborn, which is typically 110 to 160 beats per minute. Sinus tachycardia can be normal with crying or activity, and 150/min is an expected and acceptable finding that indicates a healthy circulatory status.

Choice A rationale

While bonding time is crucial for establishing parent-newborn attachment, it is not the immediate priority during the third stage of labor. The third stage is the period from the baby's birth until the placenta is delivered. The newborn's physiological stability, particularly temperature regulation and respiratory transition, takes precedence over private bonding immediately after birth.

Choice B rationale

Applying identification bands is a critical safety measure to prevent infant abduction or mix-up. However, it is not the absolute first action the nurse should take. Thermoregulation and initial stabilization, such as drying, are the immediate priorities to prevent cold stress and ensure the newborn's physiological adaptation before applying bands or allowing prolonged bonding.

Choice C rationale

Drying the newborn with clean towels is the first and most critical action to prevent heat loss through evaporation. Immediate drying and removing the wet linens are essential for thermoregulation and preventing cold stress, which can lead to increased oxygen consumption and metabolic acidosis. This action also provides tactile stimulation, which can help initiate or sustain respirations.

Choice D rationale

Checking the newborn's axillary temperature is an essential step for monitoring thermoregulation. However, it is an assessment action that follows the intervention of drying the baby. Immediate drying is the priority to prevent heat loss and stabilize the baby's temperature; the temperature check is then used to evaluate the effectiveness of the warming measures.