Which newborn reflex elicits the following reaction: Head turns to one side - the way the head is facing, the arm/leg is stretched out while the other is bent?

Choice A reason:

Acrocyanosis (choice A) is a common and relatively normal finding in newborns, especially in the first few days of life. It refers to the bluish discoloration of the hands and feet due to peripheral vasoconstriction. Acrocyanosis alone does not necessarily indicate significant difficulty with oxygenation and is usually a transient and benign condition.

Choice B reason:

A respiratory rate of 54 breaths/minute (choice B) is within the normal range for a newborn. The normal respiratory rate for a newborn can range from 30 to 60 breaths per minute. While an abnormal respiratory rate outside this range may be a concern, a rate of 54 breaths/minute is not indicative of significant oxygenation difficulty by itself.

Choice C reason:

Nasal flaring in a newborn is a concerning sign that suggests the baby is experiencing difficulty with oxygenation. When a newborn is having trouble getting enough oxygen, they may instinctively open their nostrils wider (nasal flaring) to increase the airflow into the nose and improve oxygen intake. This is a compensatory mechanism to overcome respiratory distress and is often seen in newborns with respiratory problems. Nasal flaring is an important clinical sign that indicates the baby may be struggling to breathe adequately and requires further evaluation and intervention by the healthcare team.

Choice D reason:

Abdominal breathing (choice D) is a normal breathing pattern in newborns. Newborns predominantly use their diaphragm to breathe, which results in abdominal movements during respiration. This is a normal and expected finding in healthy newborns and does not necessarily suggest oxygenation problems.

Assist the client to turn onto her side. This is the correct answer because turning the client onto her side can improve blood flow to the placenta and increase fetal oxygenation. Hypotension is a common cause of decreased uteroplacental perfusion, which can lead to fetal distress and late decelerations on the fetal monitor. The nurse should also administer oxygen, increase IV fluids, and notify the provider. • Choice B reason:

Prepare for an immediate vaginal delivery. This is not the correct answer because there is no indication that the client is ready for delivery. The client has 6 cm of cervical dilation, which means she is still in the active phase of labor. The second stage of labor begins when the cervix is fully dilated (10 cm) and ends with delivery of the baby. Preparing for an immediate vaginal delivery would not address the cause of hypotension or improve fetal oxygenation. • Choice C reason:

Prepare for a cesarean birth. This is not the correct answer because there is no indication that the client needs a cesarean birth. A cesarean birth may be indicated if there are signs of fetal compromise, such as severe variable or late decelerations, or maternal complications, such as placenta previa or cord prolapse. However, these conditions are not present in this scenario. Preparing for a cesarean birth would not address the cause of hypotension or improve fetal oxygenation. • Choice D reason:

Assist the client to an upright position. This is not the correct answer because placing the client in an upright position can worsen hypotension and decrease uteroplacental perfusion. An upright position can increase pressure on the inferior vena cava and reduce venous return to the heart. This can lower cardiac output.