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    Ati demsn maternal newborn proctored exam

    During the initial assessment of a newborn, the nurse observes that the umbilical cord contains two arteries and one vein. Which nursing action is most appropriate?

    Explanation & Rationale

    A. Notify the healthcare provider, as this finding may be associated with congenital anomalies: Two arteries and one vein represent the normal anatomy of the umbilical cord. Notification is unnecessary unless only one artery (a single umbilical artery) is present, which could indicate possible congenital anomalies. B. Document the finding as normal and continue with routine newborn care: The normal umbilical cord structure consists of two arteries that carry deoxygenated blood from the fetus and one vein that returns oxygenated blood to the fetus. This finding confirms a normal cord and requires no additional interventions beyond standard care. C. Apply warm compresses to the cord to promote circulation: The umbilical cord no longer functions in circulation after birth. Applying warm compresses would serve no purpose and could introduce unnecessary risk of infection or injury to the cord stump. D. Document the finding as abnormal and continue with routine newborn care: Labeling a normal finding as abnormal could lead to confusion in medical records and unnecessary evaluations. Proper documentation should accurately reflect the expected normal anatomy of two arteries and one vein.

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