Which step is most appropriate following delivery of a healthy newborn?

Correct Answer: B

Rationale: Step 1: Placing the newborn skin to skin in the mother's arms helps with bonding, regulates the baby's temperature, and promotes breastfeeding initiation. Step 2: Skin-to-skin contact supports the baby in transitioning to the outside world comfortably. Step 3: Keeping the baby dry and close to the mother promotes a sense of security and comfort. Step 4: This approach aligns with evidence-based practices for newborn care. Summary: A: Assessing the newborn's temperature rectally is not the immediate priority after delivery. C: Placing the baby under the radiant warmer may disrupt bonding and delay skin-to-skin contact. D: Wrapping the baby in warm blankets without skin-to-skin contact may lead to heat loss and hinder maternal-infant bonding.

Correct Answer: B

Rationale: The correct answer is B because infants born before 34 to 36 weeks gestational age may not have fully developed surfactant production, which is crucial for alveolar stability and lung expansion. Surfactant reduces surface tension in the alveoli, preventing their collapse. Without sufficient surfactant, preterm infants are at risk of respiratory distress syndrome. Choice A is incorrect because infants born at 32 weeks may still have underdeveloped alveoli and insufficient surfactant production, leading to potential lung expansion issues. Choice C is incorrect because the presence of gestational diabetes does not guarantee sufficient lung maturity in preterm infants. Lung maturity is more closely related to gestational age and surfactant production. Choice D is incorrect because while carrying multiple fetuses can slightly increase surfactant production, it may not be sufficient for preterm infants born before 34 to 36 weeks, necessitating the need for exogenous surfactant administration.

Correct Answer: D

Rationale: The correct answer is D because swaddling helps maintain the infant's body temperature by preventing heat loss. Swaddling creates a cocoon-like environment, reducing exposure to external factors. Choice A is incorrect because a baby scale does not provide warmth. Choice B is incorrect as the preterm infant is in an extended position, which increases heat loss. Choice C is incorrect as the term infant lying next to the door may experience drafts and heat loss.

Correct Answer: A

Rationale: The correct next course of action is to obtain a blood glucose reading (Choice A). Poor muscle tone and low temperature in a newborn can be indicative of hypoglycemia, which is a common issue in infants. By checking the blood glucose level, the healthcare provider can determine if hypoglycemia is the cause of the symptoms. This action allows for prompt intervention if needed. Choices B, C, and D are incorrect as they do not address the potential underlying issue of hypoglycemia. Resuscitation needs (Choice B) should only be considered if the infant's condition deteriorates. Calling for a transfer to the neonatal intensive care unit (Choice C) may not be necessary if the issue can be managed in the nursery. Placing warm blankets (Choice D) may help with temperature regulation but does not address the root cause of the symptoms.

Correct Answer: B

Rationale: The correct answer is B: Parent-to-newborn attachment may be a concern. The nurse is most concerned about the lack of bonding or attachment between the mother and her newborn, as indicated by the mother not having thought about a name yet. This lack of interest or engagement with the newborn could potentially impact the mother's ability to form a healthy attachment, which is crucial for the newborn's well-being. The nurse should prioritize assessing and supporting the mother in developing a bond with her baby. Choices A, C, and D are incorrect: A: The patient not naming the newborn does not indicate she has not transitioned from the fourth stage of labor. C: There is no evidence to suggest that the mother may be contemplating suicide based solely on her not naming the newborn. D: Different cultural practices do not seem to be the primary concern in this scenario compared to the potential lack of parent-to-newborn attachment.