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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.

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.

Promoting normal respirations is a priority in 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.

10% to 15% of their birth weight. This is incorrect because this range is too high for a normal newborn weight loss. Losing more than 10% of their birth weight may indicate dehydration, inadequate feeding, or other problems. •

20% of their birth weight. This is incorrect because this percentage is way too high for a normal newborn weight loss. Losing 20% of their birth weight would be a serious sign of illness or malnutrition. •

15% to 18% of their birth weight. This is incorrect because this range is also too high for a normal newborn weight loss. Losing 15% to 18% of their birth weight would be a cause for concern and require further evaluation. •

Change her position to the right side. This is not correct because changing the position to the right side may not improve the fetal blood flow and oxygenation. The left lateral position is usually preferred because it reduces the compression of the inferior vena cava and the aorta by the gravid uterus. •

Place a wedge under the left hip. This is not correct because placing a wedge under the left hip may increase the pressure on the vena cava and reduce the venous return to the heart. This may worsen the fetal hypoxia and acidosis. •

Lower the head of the bed. This is not correct because lowering the head of the bed may increase the uterine perfusion pressure and decrease the placental blood flow. This may also aggravate the fetal distress. •

Inspecting if the urethral opening appears circular. This is a correct action for the nurse to do, as it helps to identify any abnormalities in the urethral opening, such as hypospadias or epispadias, which are congenital defects where the opening is located on the underside or the top of the penis, respectively. •

Palpating if testes are descended into the scrotal sac. This is a correct action for the nurse to do, as it helps to detect any undescended testes, which are more common in preterm infants and can increase the risk of infertility and testicular cancer later in life. •

Inspecting the genital area for irritated skin. This is a correct action for the nurse to do, as it helps to identify any signs of diaper rash, fungal infection, or allergic reaction in the newborn's skin.

Wrapping the baby in warmed blankets is the best action to prevent heat loss from convection, as it reduces the exposed surface area of the newborn's skin and provides insulation from the cooler air. This helps maintain the newborn's core temperature and avoid hypothermia.

Placing the baby in a warmer is another way to prevent heat loss from convection, as it provides a controlled environment with a constant temperature. However, this is not always feasible or necessary, especially if the newborn is stable and does not require intensive care. Wrapping the baby in warmed blankets is a simpler and more accessible method that can be done in any setting.

Moving infant away from blowing fan is a good measure to prevent heat loss from convection, as it reduces the airflow that can carry heat away from the newborn's skin. However, this is not sufficient to prevent heat loss from convection, as there may still be other sources of cool air in the environment. Wrapping the baby in warmed blankets is more effective and comprehensive in preventing heat loss from convection.

The Moro reflex, also called the startle reflex, is the baby's reaction to being startled. The cause is often a loud sound, a sudden movement, or even their own cry. As an adult, you may jump or gasp when you are startled. A baby will throw back their head, extend their arms and legs, cry, then pull their arms and legs back in. This reflex does not match the description of the question.

The startled reflex is not a distinct reflex in newborns. It is another name for the Moro reflex, which is explained.

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. •

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. •

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.

nations are normal responses that indicate the fetus is healthy and active. Accelerations occur when the fetal heart rate increases in response to stimuli. •

accelerations are nonreassuring patterns that indicate fetal hypoxia due to placental insufficiency. Late decelerations occur when the placental blood flow decreases due to uterine contractions during labor, causing the fetal heart rate to decrease. •

decelerations are reassuring patterns that indicate a neural reflex due to fetal head compression. Early decelerations occur when the fetal head is compressed by uterine contractions during labor, causing the parasympathetic nervous system to be stimulated and the heart rate to decrease. The correct answer is C. Variable decelerations are the most common pattern that indicate a problem with the umbilical cord and require urgent intervention.

This is not the best response because it does not address the husband's concern or offer any intervention for the client's pain. Asking the client to rate her pain on a scale of 0 to 10 is a subjective assessment tool that may not reflect the true intensity of her pain. Furthermore, it may be difficult for the client to answer this question while she is in the second stage of labor.

This is not the best response because it may not be feasible or appropriate to administer more pain medication to the client in the second stage of labor. The obstetrician may not be available to evaluate the client's pain, and increasing the dose of pain medication may have adverse effects on the client and the fetus, such as respiratory depression, hypotension, and decreased uterine contractility.

This is not the best response because it does not acknowledge the husband's feelings or provide any comfort or education for him. Reassuring him that his wife will be fine may sound dismissive and insensitive, and offering to stay with her while he takes a walk may imply that he is not needed or wanted in the birthing room. The nurse should involve the husband in the care of his wife and explain to him what is happening and what to expect during labor.

Assisting the client into a comfortable position (Choice A) might be appropriate in some labor scenarios, but in this case, the client's sudden urge to push indicates that the baby's birth is imminent. Therefore, the nurse should focus on evaluating the stage of labor and preparing for delivery rather than repositioning the client.

The correct action for the nurse to take is to observe the perineum for signs of crowning (Choice B). Crowning is the appearance of the baby's head at the vaginal opening during the second stage of labor, which indicates that delivery is imminent. It is crucial for the nurse to be aware of this sign to assist with the safe delivery of the baby.

Helping the client to the bathroom to void (Choice D) is not advisable at this point. The client's urge to push indicates that the baby is descending, and birth is imminent. It would not be safe to have the client walk to the bathroom at this stage, as she may deliver the baby during the process, increasing the risk of an unattended birth.