A nurse is caring for four newborns. Which of the following newborns should the nurse assess first?

Correct Answer: A

Rationale: Nasal flaring in a newborn can be a sign of respiratory distress, which is a critical condition that requires immediate attention. It indicates that the newborn is having difficulty breathing and may not be getting enough oxygen. This can be due to various reasons such as lung problems, infections, or other respiratory issues. Therefore, the nurse should assess and address the newborn with nasal flaring first to ensure their breathing is stable and adequate.

Correct Answer: A

Rationale: The correct order of implementation in this scenario should focus on addressing the immediate physiological needs of the patient. The vital signs indicating hypovolemia from dehydration require prompt action to stabilize the patient's condition. Giving 1L of LR IV will help reestablish vascular volume, improve blood pressure, and address the underlying issue of dehydration. By addressing the hypovolemia first, the nurse can effectively start the process of stabilizing the patient before moving on to other interventions such as weighing the client, administering Maalox orally, or encouraging liquid intake.

Correct Answer: C

Rationale: The newborn infant whose umbilical cord fell off on day 8 of life is at highest risk of a skin infection. This is because the umbilical cord stump is an area prone to bacterial colonization and can lead to infection if proper care is not maintained during the cord care period. Once the umbilical cord falls off, the skin in that area is exposed and vulnerable to infection. It is important to educate parents on proper cord care techniques to prevent infection in this high-risk period.

Correct Answer: A

Rationale: The priority action for a nurse to take when observing a slowing of the fetal heart rate after the start of a contraction, with the lowest rate occurring after the peak of the contraction, is to place the client in the lateral position. This position, specifically the left lateral position, can alleviate pressure on the vena cava, improve blood flow to the placenta, and help optimize fetal oxygenation. By changing the client's position, the nurse can potentially relieve the decelerations seen in the fetal heart rate and promote better oxygenation for the fetus. This intervention is effective and can be quickly implemented in a labor and delivery setting to support fetal well-being.

Correct Answer: B

Rationale: Crowning occurs when the fetal head becomes visible at the vaginal opening, indicating that birth is imminent.