The nurse reviews the assessment findings along with the healthcare provider's prescriptions.
Which immediate intervention(s) would the nurse initiate? Select all that apply.

Choice A rationale

Bathing the newborn in warm water and swaddling in 2 blankets is not the best immediate action to prevent cold stress. While keeping the newborn warm is crucial, bathing immediately after birth can lead to rapid heat loss, and swaddling alone may not provide sufficient warmth.

Choice B rationale

Placing the newborn on a radiant warmer is an effective method to prevent cold stress, but it is not as beneficial as skin-to-skin contact, which provides both warmth and bonding. Radiant warmers are used primarily in situations where the infant requires stabilization or when skin-to-skin is not feasible.

Choice C rationale

Maintaining a room temperature above 70° F (21.1° C) helps to create a warmer environment, but it does not address the immediate need to prevent heat loss in the newborn. Room temperature alone may not be adequate to prevent cold stress, especially in preterm or low birth weight infants.

Choice D rationale

Drying off the newborn and placing them skin-to-skin with the mother is highly effective in preventing cold stress. This technique promotes thermal regulation through direct skin contact, which transfers body heat from the mother to the infant, stabilizes body temperature, and supports bonding and breastfeeding.

Choice A rationale

Palpating the suprapubic area to assess fetal head position is not relevant to identifying the source of fluid leakage. This technique is used to evaluate fetal engagement in the pelvis, particularly near term, but it does not help in determining whether the fluid leakage is amniotic fluid or urine.

Choice B rationale

Scanning the bladder for urinary retention is unrelated to identifying the nature of fluid leakage. A bladder scan is useful for detecting residual urine volume in the bladder, often post-voiding, and is typically used in cases of urinary retention or post-operative care.

Choice C rationale

Testing the fluid with a nitrazine strip is a standard method to distinguish amniotic fluid from urine or vaginal secretions. Amniotic fluid has a higher pH (usually between 7.0 and 7.5), causing the nitrazine strip to turn blue, whereas urine and vaginal secretions usually have a lower pH, resulting in a yellow or green color on the strip.

Choice D rationale

Inserting a straight urinary catheter to drain the bladder is an invasive procedure that does not directly identify the source of fluid leakage. This technique is typically used to relieve urinary retention or to collect a sterile urine specimen, not for diagnosing amniotic fluid leakage.