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: 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.

Choice A rationale

While thermoregulation is critical for newborns, directly placing a newborn with an omphalocele under a radiant heat source without covering the exposed viscera first can lead to excessive fluid loss and potential hypothermia due to evaporation. The primary concern is protecting the exposed abdominal contents from injury and infection.

Choice B rationale

Positioning a newborn with an omphalocele in a supine position is generally appropriate, as it helps to keep the exposed viscera in a less compromised position. However, the most immediate and critical action is to protect the exposed organs from trauma, desiccation, and infection before considering positioning.

Choice C rationale

Using sterile plastic wrap to cover the viscera of a newborn with an omphalocele is a critical immediate nursing action. This creates a sterile barrier, prevents desiccation of the exposed abdominal contents, minimizes heat and fluid loss, and reduces the risk of infection, thus protecting the delicate organs until surgical repair.

Choice D rationale

Applying petroleum gauze to the exposed viscera is not the most appropriate or effective method for protecting an omphalocele. Petroleum gauze may stick to the delicate tissues, potentially causing trauma upon removal, and does not provide the same level of sterile barrier, moisture retention, or protection against environmental contaminants as sterile plastic wrap.