The nurse is caring for a neonate born at 36 weeks, 2 days by primary cesarean birth and weighing 6 pounds, 4 ounces. The infant cried at delivery, had flexion in all extremities, had a heart rate of 135, had acrocyanosis in hands and feet, and was pale. The infant was placed skin-to-skin with the birthing person and has been latching and cuddling for the past 15 minutes. At 45 minutes, the neonate is found grunting and cool to the touch. What are the nurse's next steps?

Correct Answer: C

Rationale: The correct answer is C: Take the neonate to the radiant warmer and check their temperature. This is the appropriate next step because the neonate is showing signs of potential respiratory distress (grunting) and coolness to the touch, which could indicate hypothermia. Placing the neonate in the radiant warmer will help maintain a stable temperature and facilitate further assessment and intervention. Choice A is incorrect because stimulating the neonate to take deep breaths may not address the underlying issue of potential respiratory distress. Choice B is incorrect because simply wrapping the baby in blankets and cuddling them closer may not address the potential respiratory distress or hypothermia that the neonate is exhibiting. Choice D is incorrect because calling the NICU staff and activating the staff assist light should be done after assessing the neonate's immediate needs, such as addressing potential respiratory distress and hypothermia.

Correct Answer: B

Rationale: The correct answer is B because a cephalohematoma is a collection of blood between the skull bone and its periosteum. It is usually unilateral and does not cross suture lines. Choice A is incorrect because cephalohematomas do not appear suddenly. Choice C is incorrect as cephalohematomas do not cause the head to feel boggy or cross suture lines. Choice D is incorrect because the mass does not increase in size when the infant cries.

Correct Answer: A

Rationale: The correct answer is A because eliciting the rooting reflex in a newborn involves gently rubbing a finger on the side of the cheek. This reflex is important for feeding as it helps the baby turn their head towards the stimulus to locate the nipple for feeding. This action triggers a sucking response. The other choices are incorrect as they do not specifically target the rooting reflex. Choice B refers to the palmar grasp reflex, choice C is related to the sucking reflex, and choice D describes the Moro reflex. These reflexes are different from the rooting reflex and have distinct elicitation methods.

Correct Answer: B

Rationale: The correct answer is B because a full-term newborn typically has well-curved pinna that is soft and has a ready recoil. This indicates normal ear development and flexibility in newborns. Choice A is incorrect as a slightly curved pinna with slow recoil is not characteristic of a full-term newborn. Choices C and D are incorrect as thick cartilage with a stiff ear or a flat pinna that stays folded are not typical findings in full-term newborns. Therefore, the characteristics described in choice B align with normal ear development in a full-term newborn.

Correct Answer: D

Rationale: The correct answer is D because lanugo, the fine hair that covers a newborn's body, is commonly found on the back between the scapulae. This area is where lanugo is most prominent and noticeable. Lanugo is not typically found on the newborn's face (choice A) or extremities (choice B). While some lanugo may be present on the newborn's back near their buttocks (choice C), it is not the primary location for this fine hair to be observed. Therefore, choice D is the correct answer based on the typical distribution of lanugo on a newborn's body.