A nurse is performing a physical examination of a term newborn upon admission to the nursery.
In which order should the nurse perform the following assessments?

Choice A rationale

The specific volume of formula for gavage feeding a newborn, such as 20 mL, depends on the newborn's weight, gestational age, and clinical condition. A blanket recommendation of 20 mL without this individualized assessment is inappropriate and could lead to over or underfeeding, impacting growth and gastrointestinal tolerance.

Choice B rationale

Placing a newborn in a supine position immediately after gavage feedings increases the risk of aspiration, especially for infants with immature swallowing reflexes or reflux. The newborn should be positioned on their right side or semi-Fowler's position to facilitate gastric emptying and minimize aspiration risk.

Choice C rationale

While cluster feeding (multiple feedings close together) is a natural pattern for some breastfed infants, for gavage feeding, regular, scheduled intervals are typically maintained to ensure consistent nutrient delivery and proper digestion, especially in newborns who are medically fragile. Cluster feeding is not a standard gavage feeding practice.

Choice D rationale

Nonnutritive sucking (e.g., pacifier use) during gavage feedings is crucial for promoting oral motor development and associating the feeling of fullness with sucking. This helps prevent oral aversion and prepares the newborn for eventual oral feeding, stimulating gastric secretions and improving digestion.

Choice A rationale: Ensuring suction is available is critical because clients with severe preeclampsia or eclampsia are at risk for seizures that can cause airway obstruction from secretions or vomiting. Suction readiness supports immediate airway management during a seizure, preventing aspiration and maintaining oxygenation, essential in protecting maternal and fetal health.

Choice B rationale: Administering 10 L of oxygen via nasal cannula is not appropriate because nasal cannulas typically deliver oxygen up to 6 L/min; higher flows require a different delivery system like a non-rebreather mask. Also, routine high-flow oxygen is not indicated unless hypoxia is present. The client’s oxygen saturation is normal (99%), so supplemental oxygen at this rate is unnecessary and could cause discomfort or drying of mucous membranes.

Choice C rationale: Raising side rails is a safety measure to prevent injury during seizures or sudden movements caused by central nervous system irritability in preeclampsia. Elevated side rails help protect the client from falls or trauma if a seizure occurs, an essential precaution in clients with neurological symptoms such as hyperreflexia and clonus.

Choice D rationale: Placing a padded tongue blade at the bedside prepares for seizure management by preventing tongue biting and airway obstruction. The padded blade reduces the risk of oral trauma during convulsions and maintains airway patency. However, it should be used carefully to avoid airway injury or obstruction and only if a seizure occurs.

Choice E rationale: Dimming lights reduces environmental stimuli that may exacerbate neurological irritability or trigger seizures in preeclampsia/eclampsia. Bright or flashing lights can increase CNS excitation, worsening headache, visual disturbances, or seizure risk. Creating a calm, low-stimulation environment helps stabilize the client’s neurological status.

Choice F rationale: Placing the client in the supine position is contraindicated because it compresses the inferior vena cava, reducing venous return and cardiac output, potentially worsening placental perfusion. The left lateral position is preferred in hypertensive pregnancy to optimize uteroplacental blood flow and maternal hemodynamics, improving fetal oxygenation and maternal comfort.