A nurse is caring for an infant born at 40 weeks of gestation.
Which of the following findings should the nurse expect?

Choice A rationale

Drying and covering the infant helps prevent heat loss and maintain body temperature, which is essential for newborns immediately after birth.

Choice B rationale

Stimulating the infant to cry helps clear the airways but is usually done after ensuring the respiratory tract is clear.

Choice C rationale

Clearing the respiratory tract is the priority immediately after birth to ensure the newborn can breathe properly and reduce the risk of aspiration.

Choice D rationale

Assessing the umbilical cord is important but not the first priority. Ensuring the airway is clear takes precedence to establish effective breathing. .

Choice A rationale

A large ecchymotic caput succedaneum, which is swelling of the scalp due to birth trauma, usually resolves within a few days. However, its large size and presence of bruising should be monitored for potential complications such as jaundice.

Choice B rationale

Yellow discoloration of the sclera and oral mucosa indicates jaundice, which can be due to hyperbilirubinemia. This condition requires follow-up and possible treatment to prevent severe complications.

Choice C rationale

A level and soft fontanel in a newborn is a normal finding. It does not require follow-up as it indicates that intracranial pressure is normal.

Choice D rationale

A respiratory rate of 78/min in a newborn is significantly higher than the normal range (30-60/min). This finding requires follow-up to assess for respiratory distress or other underlying conditions.