A nurse is caring for a newborn immediately following birth. Which of the following nursing interventions is the highest priority?

Choice A rationale

Unlicensed Assistive Personnel (UAP) are generally not permitted to perform invasive procedures or tasks that require specialized nursing knowledge, sterile technique, or clinical judgment, such as accessing or drawing blood from a central venous catheter. This procedure carries risks of infection and occlusion, requiring a licensed nurse.

Choice B rationale

Counseling, patient education, and support group referrals for complex medical conditions like leukemia require the specialized knowledge and judgment of a Registered Nurse (RN). A Licensed Practical Nurse (LPN) may reinforce teaching but initiating contact and providing detailed support information is outside their typical scope of practice for an oncology patient.

Choice C rationale

Administration of chemotherapeutic agents is a high-risk intervention that requires specialized certification and extensive training due to the potent nature of the drugs and the serious potential for adverse effects. This task is most appropriate for a chemotherapy-certified Registered Nurse to ensure patient safety and adherence to strict protocols.

Choice D rationale

A dietitian's role is to assess and manage nutritional status. Checking meal trays for intake is a routine assessment that can be completed by any member of the care team, including a UAP or nurse. However, the primary responsibility for complex nutritional assessment belongs to the dietitian, making this a fitting assignment for them.

Choice A rationale

While voiding is expected, the normal range for the first void is typically within the first 24 to 48 hours of life. A newborn not voiding at exactly 24 hours warrants continued monitoring, but it is not an immediate emergency unless there are other signs of distress or an obvious obstruction.

Choice B rationale

Acrocyanosis is a normal, transient condition in the newborn characterized by a bluish discoloration of the hands and feet due to sluggish peripheral circulation. It is common for up to 24 hours after birth and does not require immediate intervention, only ongoing assessment to ensure central color is pink.

Choice C rationale

Most healthy newborns pass meconium, the first stool, within the first 24 hours of life, with almost all passing it by 48 hours. A lack of meconium passage at 24 hours requires investigation for potential intestinal issues, such as Hirschsprung's disease or meconium plug, but an elevated temperature signals more acute distress.

Choice D rationale

A temperature of 100.5 degrees F (38.1 degrees C) in a newborn, which is above the normal range (typically 97.7 to 99.5 degrees F or 36.5 to 37.5 degrees C), is a serious finding. Newborns are susceptible to rapid temperature changes, and hyperthermia can indicate sepsis, dehydration, or environmental issues requiring immediate assessment and intervention.