The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate is 174 beats/minute. What is the priority nursing action?

Correct Answer: C

Rationale: A fetal heart rate above 160 bpm at term may indicate fetal distress, requiring immediate notification of the HCP.

Correct Answer: D

Rationale: Sternal retractions in a newborn may indicate respiratory distress or difficulty breathing. It is important for the nurse to intervene and assess the newborn's respiratory status further as this finding could be a sign of underlying respiratory issues that require immediate attention. The nurse should monitor the newborn's oxygen saturation, respiratory rate, and any other signs of distress to ensure appropriate intervention is provided promptly.

Correct Answer: B

Rationale: A male infant delivered at 28 weeks gestation, as described, would likely have very underdeveloped skin due to the premature birth. The premature skin is often transparent, allowing the prominent blood vessels underneath to be visible, and may also have a reddish hue due to the skin's immaturity. This characteristic appearance is a common finding in premature infants and is a result of their skin being thinner and more fragile than that of full-term infants. The other options, such as a wide, staring eye, an absence of lanugo, and a scrotum with descended testicles, are not specifically associated with premature birth and are not likely to be observed in this scenario.

Correct Answer: A

Rationale: Administering oxygen and positioning the newborn can improve respiratory function.

Correct Answer: B

Rationale: Sexual activity should be resumed based on the healthcare provider's recommendation, not just the cessation of bleeding.