Nokea
The nurse is assessing a newborn immediately after birth. After assigning the first Apgar score
of 9, the nurse notes two vessels in the umbilical cord. What is the nurse’s next action?
Correct Answer: A
Rationale: The correct answer is A. The nurse should assess for other abnormalities of the infant because the presence of two vessels in the umbilical cord (a condition known as a two-vessel cord) may be associated with other congenital anomalies. By assessing for other abnormalities, the nurse can identify any potential issues that may require immediate intervention or further evaluation. This proactive approach ensures the newborn's well-being and allows for timely management of any additional concerns.
Summary of other choices:
B: Noting the finding in the chart is important but does not address the immediate need to assess for other abnormalities.
C: Notifying the health care provider is important, but assessing for other abnormalities should be the nurse's initial priority.
D: Calling for the neonatal resuscitation team is not necessary based solely on the presence of a two-vessel cord; further assessment is needed before determining the need for resuscitation.