A nurse is assessing a newborn upon admission to the nursery. Which of the following should the nurse expect?

Correct Answer: D

Rationale: When a nurse is assessing a newborn upon admission to the nursery, it is expected that the chest circumference will be smaller than the head circumference. This is a normal finding in a newborn, where the head circumference is slightly larger than the chest circumference due to the proportionate sizes of the newborn's head and chest. This difference helps accommodate the vital organs within the chest cavity while allowing for the growth and development of the brain. Therefore, a chest circumference that is 2 cm smaller than the head circumference is a typical and expected finding in a newborn assessment.

Correct Answer: C

Rationale: The correct action the nurse should include in the care plan for a newborn undergoing phototherapy using a lamp is to ensure that the newborn's eyes are closed beneath the shield. This is important to protect the newborn's eyes from exposure to the bright light emitted during phototherapy, as prolonged exposure can lead to eye damage. Keeping the eyes closed under the shield helps prevent potential harm and ensures the safety and well-being of the newborn during the treatment. Applying a thin layer of lotion, giving glucose water, or dressing the newborn in clothing are not relevant or appropriate actions for phototherapy care in this scenario.

Correct Answer: D

Rationale: At the 24-week prenatal appointment, it is essential to conduct the blood type and Rh test for the pregnant client. Determining the mother's blood type (A, B, AB, O) and Rh factor (positive or negative) is crucial as it helps identify if the mother is Rh-negative and at risk for Rh incompatibility with her baby. This information is vital for appropriate management to prevent potential complications such as hemolytic disease of the newborn. Conducting the blood type and Rh test at this stage allows healthcare providers to take necessary precautions to protect both the mother and the fetus.

Correct Answer: C

Rationale: Cephalohematoma is a collection of blood between the skull and its periosteum that occurs due to rupture of blood vessels during birth trauma. It is typically found on one side of the head and does not cross the suture line. In contrast, caput succedaneum is a diffuse swelling that occurs on the newborn's scalp and can cross the suture lines. Nevus flammeus is a vascular birthmark that appears as a pink or red patch on the skin, unrelated to trauma. Erythema toxicum is a benign rash that appears as red spots or patches with a white or yellow papule in the center, also unrelated to trauma.

Correct Answer: D

Rationale: When a baby is born with an unexpected defect, it is crucial for the nursing staff to explain the defect to the parents and show the baby to them as soon as possible. This approach allows for open communication, transparency, and the opportunity for the parents to start processing the situation emotionally. By involving the parents and keeping them informed, trust and understanding can be established between the healthcare providers and the family, ultimately fostering a supportive environment for everyone involved in the care of the baby. It is essential to approach the situation with empathy and sensitivity while providing the necessary information to the parents.