An infant at term was born at 0105 hours. The nurse is developing a plan of care for the newborn. During which time range will the nurse plan on performing the assessment to determine a Ballard score?

Correct Answer: B

Rationale: The correct answer is B (0200 to 0600) because the Ballard score is typically assessed within the first 12-24 hours of life. Given that the infant was born at 0105 hours, the nurse should plan on performing the assessment between 0200 to 0600. This time frame falls within the recommended window for assessing the Ballard score accurately. Choices A, C, and D are incorrect because they fall outside the optimal time range for conducting the assessment. Option A (0115 to 0130) is too soon after birth, and options C (1400 to 1800) and D (2000 to 2300) are too late for the initial assessment as per standard practice.

Correct Answer: A

Rationale: The correct answer is A: The neonate with a birth weight of 4,100 g. Gestational age assessment is typically done based on birth weight, as it is a more accurate indicator than other factors like labor duration or exposure to medications. A birth weight of 4,100 g is considered to be indicative of a full-term baby, which is usually around 37-42 weeks gestation. Other choices like B (neonate born at 37 weeks) could be a premature or post-term baby, C (born after 18-hour labor) doesn't directly indicate gestational age, and D (exposed to oxytocin) is not a reliable indicator of gestational age. Weight is a key factor in determining gestational age, making choice A the most appropriate for the nurse to perform the assessment.

Correct Answer: B

Rationale: The correct answer is B because newborns typically go through a period of deep sleep immediately after birth. This state is characterized by decreased responsiveness to external stimuli and lower respiratory and heart rates. It is important for the nurse to allow the neonate to naturally continue deep sleep as this is a normal physiological process. Picking up the neonate (choice A) may disrupt this important sleep state. Asking another nurse for assistance (choice C) may not be necessary at this point as the neonate's condition is likely normal. Notifying the caregiver (choice D) may cause unnecessary alarm as the neonate is most likely exhibiting normal behavior for this stage.

Correct Answer: C

Rationale: The correct answer is C because offering a sucrose-dipped pacifier during the nerve block procedure can help manage the newborn's pain by providing comfort and distraction through the sweet taste and sucking motion. Sucrose has been shown to have analgesic effects in newborns. Choice A is incorrect as a tourniquet is not recommended for circumcision. Choice B may help with calming but not specifically with pain management. Choice D is incorrect as numbing with ice before the nerve block may not be effective in providing adequate pain relief during the procedure.

Correct Answer: D

Rationale: The correct answer is D because the nurse does not mention the term "hyperbilirubinemia" to the mother. Instead, the nurse focuses on explaining the high level of unconjugated bilirubin causing jaundice. A: The nurse likely mentioned that the blood test does not indicate a pathological disease to reassure the mother that jaundice is a common condition in newborns. B: The nurse would have explained that the newborn's liver converts bilirubin to a water-soluble substance as part of the discussion on how bilirubin is processed in the body. C: An abundance of RBCs and their short lifespan contributing to jaundice would be relevant information that the nurse would provide to explain the underlying causes of the condition.