The nurse receives 2 newborns within the first minutes after a vaginal delivery and intervenes to establish adequate respirations.
What is the priority issue that the nurse should address to ensure the newborn’s survival?

Choice A rationale
If the child is sleeping now and is difficult to wake, this could be a sign of worsening respiratory status. Children with respiratory distress often have difficulty sleeping due to discomfort and difficulty breathing. If the child is now sleeping and difficult to wake, this could indicate a decrease in oxygen levels, leading to lethargy and decreased responsiveness. This would require immediate attention.
Choice B rationale
The vital signs provided indicate a potentially serious situation. A heart rate of 130 beats/minute is high for a 3-year-old child, indicating that the heart is working harder to pump blood. A respiratory rate of 15 breaths/minute is on the lower end of normal for a 3-year-old, which could indicate that the child is not getting enough oxygen. An oxygen saturation of 66% on a 5L face mask is dangerously low, indicating severe hypoxia. A temperature of 102.8° F(39.3° C) axillary indicates a fever, which could be a sign of infection. A blood pressure of 92/48 mm Hg is within normal range for a 3-year-old.
Choice C rationale
If the child is active and playing with toys, this could indicate that his respiratory status is not worsening. Children who are experiencing respiratory distress often have difficulty engaging in normal activities due to discomfort and shortness of breath. If the child is able to play normally, this could indicate that he is getting enough oxygen and his condition is stable.
Choice D rationale
If the child’s breathing has returned to normal, this could indicate that his respiratory status is improving. However, it’s important to continue monitoring the child closely, as respiratory conditions can change rapidly, especially in young children.

Choice A rationale
While protein is an essential nutrient for overall health and wellbeing, increasing protein intake alone is unlikely to significantly improve hemoglobin levels. Hemoglobin is a protein in red blood cells that carries oxygen, and its production depends on having enough iron, vitamin B12, and folic acid, not just protein.
Choice B rationale
During pregnancy, the volume of blood in a woman’s body increases to support the growing fetus. This increase in blood volume can dilute the blood, which can lead to a decrease in the concentration of red blood cells and hemoglobin, a condition known as physiological anemia of pregnancy. This is a normal part of pregnancy and is typically not a cause for concern.
Choice C rationale
While it’s true that many women experience changes in their hemoglobin levels during pregnancy, it’s not accurate to say that almost all women at 28-weeks gestation have anemia. Anemia is defined as a level of hemoglobin that’s lower than normal, and the normal range can vary. However, it’s important to note that the normal range for hemoglobin does decrease during pregnancy.
Choice D rationale
Iron is a key component of hemoglobin, and iron deficiency is a common cause of anemia. If a pregnant woman’s hemoglobin levels are low, taking an iron supplement might help increase these levels. However, it’s important to talk to a healthcare provider before starting any new medication or supplement.