A nurse is assisting in the care of a newborn immediately after birth. At 5 min after birth, the newborn has acrocyanosis, flexed extremities, a grimace when suctioned, a heart rate of 130/min, and a lusty cry with tactile stimulation. What should the nurse document as the newborn's 5-min Apgar score?

Choice A rationale:

Stimulate the infant to cry. While stimulating the infant to cry is a common practice to assess the newborn's respiratory function, it is not the first action the nurse should perform in this situation. The newborn may cry spontaneously or may require other interventions, such as clearing the respiratory tract, before crying.

Choice B rationale:

Clear the respiratory tract. Clearing the respiratory tract is the priority action in this scenario. It ensures that the airway is open and allows the infant to breathe effectively. This is crucial because newborns are at higher risk of respiratory distress after birth, and prompt action can prevent complications.

Choice C rationale:

Dry the infant off and cover the head. Drying the infant off and covering the head are important steps to prevent heat loss and maintain the newborn's body temperature. However, these actions can be delayed briefly until the respiratory tract is cleared, as the immediate focus should be on ensuring the infant's ability to breathe.

Choice D rationale:

Clamp the umbilical cord. Clamping the umbilical cord is a standard procedure after birth to prevent bleeding and infection. However, it is not the priority in this situation. The first step should be to ensure the newborn's airway is clear and they can breathe adequately.

Choice A rationale:

The nurse should recommend the client to increase cellulose and fluid in the diet. Cellulose is a type of fiber found in fruits, vegetables, and whole grains. Increasing fiber intake can help alleviate constipation by adding bulk to the stool and promoting regular bowel movements. Additionally, the recommendation to increase fluid intake complements the effect of fiber, as it softens the stool, making it easier to pass through the intestines. This combination of increased cellulose and fluid intake is a safe and natural way to address constipation during pregnancy without the need for medication or invasive interventions.

Choice B rationale:

Regular use of glycerine suppositories is not the best recommendation for pregnant clients experiencing constipation. Suppositories are inserted into the rectum to stimulate bowel movements and should only be used sparingly when other methods have failed. Pregnant individuals may have increased sensitivity, and it's essential to avoid unnecessary procedures or potential discomfort.

Choice C rationale:

Regular use of a laxative is also not the most suitable recommendation for a pregnant client with constipation. While laxatives can provide relief, they may lead to dependency and might have adverse effects on the developing fetus. It is best to explore safer and more natural methods before resorting to laxative use during pregnancy.

Choice D rationale:

Maintenance of good posture is essential during pregnancy for various rationales, but it is not a specific solution for constipation. While maintaining good posture can help alleviate back pain and other discomforts, it does not directly address the issue of constipation.