A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation. Which of the following actions should the nurse the nurse takes? (Click on the "Exhibit" Button for additional information about the newborn. There are three tabs that contain separate categories of date.)

Correct Answer: D

Rationale: Since the newborn was born at 35 weeks of gestation, with a birth weight of 2.3 kg and exhibiting clinical signs of hypoglycemia, one of the key priorities in caring for this newborn is monitoring for complications related to prematurity. Measuring the abdominal circumference at the level of the newborn's umbilicus every 2 hours is important in assessing for signs of abdominal distention, which could indicate necrotizing enterocolitis (NEC), a serious condition commonly seen in premature infants. Early detection through frequent abdominal circumference measurements can aid in timely intervention and management to prevent significant complications. Administering nitric oxide inhalation therapy, inserting an orogastric decompression tube with low wall suction, and providing iron-rich formula containing vitamin B12 every 2 hours are not indicated based on the information provided in the exhibit.

Correct Answer: A

Rationale: When a patient receives an epidural anesthesia during the first stage of labor, it can lead to temporary bladder dysfunction. The epidural can affect the patient's ability to feel the sensation of a full bladder and may impair the ability to voluntarily urinate. If the epidural is discontinued immediately after delivery during the fourth stage of labor, the patient may be at an increased risk of bladder distention due to the residual effects of the epidural. Therefore, monitoring for bladder distention and ensuring adequate bladder emptying is important to prevent complications.

Correct Answer: B

Rationale: Verifying informed consent is essential before proceeding with any surgical procedure.

Correct Answer: C

Rationale: The correct instruction for the nurse to include in the discharge plan is to encourage frequent feeding to increase intake. Fiber-optic blankets for treating physiologic jaundice work by promoting the breakdown of bilirubin in the skin through phototherapy. Encouraging frequent feeding helps increase the infant's intake, leading to more frequent bowel movements which aids in the elimination of excess bilirubin from the body. This, in turn, helps in resolving physiologic jaundice more quickly. Covering the infant's eyes during treatment may be necessary to protect them from the bright light, but it is not directly related to the effectiveness of the treatment. Reducing the number of formula feedings could decrease the baby's intake, potentially leading to more concentrated levels of bilirubin. Expecting constipation until jaundice clears is not a typical consequence of using a fiber-optic blanket for jaundice treatment.

Correct Answer: A

Rationale: Repositioning improves uteroplacental blood flow and oxygen delivery to the fetus, addressing late decelerations.