A nurse is completing the admission assessment of a newborn. Which of the following anatomical landmarks should the nurse use when measuring the newborn’s chest circumference?

Choice A Reason:

Witnessing the signature for informed consent for surgery is important but not the immediate priority. The client’s vital signs indicate potential hemodynamic instability (low blood pressure and high heart rate), which requires prompt intervention to stabilize the client before any surgical procedures can be considered.

Choice B Reason:

Initiating IV access is the priority action. This allows for the administration of fluids and medications, which is crucial in managing the client’s hemodynamic status. The client’s low blood pressure and high heart rate suggest hypovolemia, likely due to significant blood loss. Immediate IV access enables rapid fluid resuscitation and preparation for potential blood transfusions, which are essential to stabilize the client1.

Choice C Reason:

Inserting an indwelling urinary catheter is necessary for monitoring urine output, which is an important indicator of renal perfusion and overall fluid status. However, it is not the immediate priority compared to establishing IV access, which directly addresses the client’s hemodynamic instability.

Choice D Reason:

Preparing the abdominal and perineal areas is a preparatory step for potential surgical intervention. While important, it is not the immediate priority. Stabilizing the client’s condition through IV access and fluid resuscitation takes precedence to ensure the client is in a stable condition for any subsequent procedures.

Choice A Reason:

One of the most reliable indicators that a baby is getting enough breast milk is the number of wet diapers. A well-hydrated baby should wet at least 6 to 8 diapers per day. This indicates that the baby is receiving sufficient fluids and nutrients from breast milk. Consistent wet diapers are a clear sign that the baby is feeding well and getting enough milk.

Choice B Reason:

A wake cycle of 30 to 60 minutes after each feeding is not a reliable indicator of adequate breast milk intake. Babies have varying sleep and wake patterns, and these can be influenced by many factors other than feeding. While some babies may stay awake for a short period after feeding, this is not a definitive sign of adequate milk intake.

Choice C Reason:

Burping after each feeding is a common practice to help release any swallowed air, but it does not indicate whether the baby is getting enough breast milk. Burping is more related to the baby’s comfort and digestion rather than the quantity of milk consumed.

Choice D Reason:

Sleeping at least 6 hours between feedings is not typical for a newborn, especially in the first few weeks of life. Newborns usually feed every 2 to 3 hours, including during the night. Long sleep intervals can be a concern and may indicate that the baby is not feeding frequently enough, which could affect milk intake and hydration.