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: In this scenario, the correct next step for the nurse is option C, which is to take the neonate to the radiant warmer and check their temperature. This choice is the most appropriate because the neonate is showing signs of potential respiratory distress and hypothermia, which are critical issues that need to be addressed promptly. Option A is incorrect because simply stimulating the neonate to take deep breaths may not address the underlying issue of respiratory distress. Option B is also incorrect as wrapping the baby in blankets and cuddling closer may not adequately address the potential respiratory and temperature concerns. From an educational perspective, this scenario highlights the importance of recognizing signs of respiratory distress and hypothermia in neonates. It emphasizes the need for prompt assessment and intervention to ensure the well-being of the newborn. Understanding these critical signs and appropriate interventions is essential for nurses caring for newborns to provide safe and effective care.

Correct Answer: B

Rationale: The correct answer is B) The mass is on one side of the head and does not cross suture lines. A cephalohematoma is a collection of blood between a newborn's skull and the periosteum. This condition typically appears hours after birth, does not cross suture lines as they are bounded by periosteum, and may take weeks to months to resolve. It is usually caused by pressure during delivery and is not associated with crying or a boggy consistency in the head. Option A is incorrect because a cephalohematoma does not just appear but develops after birth. Option C is incorrect as a boggy head and crossing suture lines are characteristic of another condition called caput succedaneum. Option D is incorrect as cephalohematomas do not typically increase in size when the infant cries. For nursing students caring for newborns, understanding the differences between cephalohematoma and other neonatal head conditions is crucial for accurate assessment and appropriate intervention. This knowledge helps nurses provide accurate information to parents, offer appropriate support, and ensure the newborn's well-being.

Correct Answer: A

Rationale: The correct answer is A) Gently rub a finger on the side of the newborn’s cheek to elicit the rooting reflex. This action triggers the newborn's instinctual response to turn their head towards the stimulus and open their mouth, mimicking the movement made when seeking the breast for feeding. Option B is incorrect because putting a finger into the palm of the newborn's hand and waiting for them to grab on actually elicits the grasp reflex, not the rooting reflex. Option C is incorrect as stimulating the roof of the mouth would elicit the sucking reflex, not the rooting reflex. Option D is incorrect as grabbing both arms and pulling upward to watch for a startle response is describing the Moro reflex, not the rooting reflex. Understanding and being able to elicit newborn reflexes are essential skills for nurses caring for newborns. By correctly eliciting the rooting reflex, nurses can assess the newborn's neurological development and readiness for feeding. This knowledge helps nurses provide appropriate care and support for the newborn and family during this critical period of transition and bonding.

Correct Answer: B

Rationale: In pharmacology, understanding the physical assessment of newborns is crucial for nurses to provide safe and effective care. In this context, the correct answer is option B) well-curved pinna; soft; ready recoil. A full-term newborn typically presents with ears that are well-curved, soft to the touch, and have a quick recoil when folded. Option A is incorrect because a slightly curved pinna is not characteristic of a full-term newborn; instead, it may be seen in preterm infants. The slow recoil mentioned in option A is also not typical for a healthy newborn's ears. Option C, thick cartilage, and stiff ear, are not characteristics of a full-term newborn's ears. Newborns typically have soft and pliable cartilage in their ears. Option D, a flat pinna that stays folded, is not a typical finding in a full-term newborn. Folded ears in a newborn usually have a quick recoil, unlike the description in this option. Educationally, it is important for nurses to be able to recognize normal variations in newborn assessments to differentiate them from potential abnormalities. This knowledge helps nurses provide appropriate care and identify any potential issues early on. Understanding the expected characteristics of a full-term newborn's ears is essential for accurate assessment and care planning.

Correct Answer: D

Rationale: In assessing a newborn for the presence of lanugo, it is important to look for it on the newborn's back between the scapulae (shoulder blades). Lanugo is the fine, soft, downy hair that covers the body of a newborn. This location is where lanugo is commonly found in newborns and is a normal part of their development in utero. The other options are incorrect because: A) Lanugo is not typically found on the newborn's face. While some newborns may have fine hair on their face, this is usually not referred to as lanugo. B) Lanugo is not typically found on the newborn's extremities. The presence of lanugo on the extremities is less common compared to the back area. C) Lanugo is not typically found on the newborn's back near their buttocks. While newborns may have some hair in this area, true lanugo is more commonly found between the shoulder blades. Understanding the typical locations of lanugo on a newborn's body is essential for nurses and healthcare providers in providing comprehensive care for newborns. Recognizing normal variations in newborn appearance can help healthcare professionals assess the newborn's overall health and development accurately.