The nurse notes right cephalhematoma on the otherwise healthy one-day-old newborn. Apriority intervention at the time of discharge would be to instruct the parents:

Correct Answer: A

Rationale: In this scenario, the correct answer is option A: Instructing the parents on how to observe for signs of jaundice. Jaundice is a common condition in newborns and can be more prevalent in infants with cephalhematoma. It is essential for parents to monitor their newborn for signs of jaundice, such as yellowing of the skin or eyes, as it can indicate a potential issue with the baby's liver function. Early detection and management of jaundice are crucial to prevent complications. Option B, assessing the fontanels for tenseness, is not the priority in this case as cephalhematoma does not typically affect the fontanels. While fontanels should be assessed for normalcy, it is not the immediate concern in this situation. Option C, increasing the infant's feeding to every 3 hours, is not the priority intervention at the time of discharge for a newborn with cephalhematoma. Feeding frequency is important, but monitoring for jaundice takes precedence in this case. Option D, recording the number of wet diapers in 24 hours, is important for monitoring the newborn's hydration status but is not the priority over watching for signs of jaundice, which can have more immediate health implications. In the context of maternal newborn nursing education, it is crucial to prioritize teaching parents about common newborn conditions and associated signs and symptoms. By educating parents on how to recognize signs of jaundice early, nurses can empower them to seek timely medical intervention if needed, promoting the health and well-being of the newborn.

Correct Answer: D

Rationale: In this scenario, the correct interpretation by the nurse is "D) Respiratory Distress." The newborn's respiratory rate of 80 breaths/min, nasal flaring, sternal retractions, along with the low oxygen saturation of <87%, indicate respiratory distress. Respiratory distress in newborns can be caused by various conditions such as respiratory infections, meconium aspiration, or transient tachypnea of the newborn. Option A, "Cardiac distress," is incorrect as the symptoms presented are more indicative of respiratory rather than cardiac issues. Option B, "Respiratory Alkalosis," does not fit the clinical picture presented by the newborn. Option C, "Bronchial pneumonia," could be a consideration due to the respiratory symptoms, but the overall presentation is more indicative of generalized respiratory distress rather than a specific diagnosis like pneumonia. Educationally, it is crucial for nurses to recognize the signs and symptoms of respiratory distress in newborns as prompt intervention is essential to prevent further complications. Understanding the assessment findings and their implications helps nurses provide timely and appropriate care to newborns in distress.

Correct Answer: C

Rationale: In maternal newborn nursing, promoting parental attachment is crucial for the well-being of both the newborn and the parents. The correct nursing intervention that most promotes parental attachment upon delivery of the newborn is placing the newborn on the mother's chest and abdomen (Option C). This practice, commonly known as skin-to-skin contact or kangaroo care, has numerous benefits. It helps regulate the newborn's temperature, heart rate, and breathing, promotes bonding between the parent and the newborn, enhances breastfeeding initiation, and reduces stress for both the parent and the infant. It also stimulates the release of oxytocin, the "love hormone," which further strengthens the attachment between the parent and the newborn. Option A, placing the infant under the radiant warmer, is incorrect because it disrupts immediate parent-newborn bonding. Option B, allowing the mother to rest immediately after delivery, is important but should not take precedence over the crucial first moments of bonding. Option D, taking the newborn to the nursery for the initial assessment, also disrupts the immediate bonding and can delay important skin-to-skin contact. In the educational context, it is essential for nursing students to understand the significance of promoting parental attachment in the immediate postpartum period. By prioritizing skin-to-skin contact, nurses can support the emotional and physiological needs of both the parent and the newborn, fostering a strong foundation for their relationship and overall well-being.

Correct Answer: B

Rationale: In maternal newborn nursing, assessing newborns' gestational age and weight is crucial for determining their overall health and development. In this scenario, the correct classification for a newborn delivered at 39 weeks' gestation, weighing 2400 g (5.0 lbs) is "B) Small-for-gestational age." This classification is correct because the newborn's weight is below the 10th percentile for their gestational age, indicating intrauterine growth restriction. This condition can be caused by various factors such as maternal health issues, placental problems, or genetic factors, leading to a smaller-than-expected newborn size. Option A, "Preterm and immature," is incorrect because the newborn was delivered at 39 weeks' gestation, which is considered full-term. Option C, "Average-for-gestational age," is incorrect as the newborn's weight falls below the expected range for their gestational age. Option D, "Average-for-gestational age but preterm," is also inaccurate as the newborn is not preterm but rather small for their gestational age. Educationally, understanding classifications like small-for-gestational age is essential for nurses to provide appropriate care and interventions for these newborns, such as monitoring for complications, ensuring adequate nutrition, and promoting growth and development. This knowledge helps nurses tailor their care plans to meet the specific needs of these vulnerable infants.

Correct Answer: A

Rationale: In the scenario of a newborn experiencing cold stress, the primary nursing intervention is to minimize oxygen consumption to prevent further complications. Therefore, the correct answer is C) Oxygen consumption. Cold stress can lead to increased oxygen demand as the body tries to generate heat to maintain normal body temperature. By minimizing oxygen consumption, the newborn's energy expenditure can be reduced, helping to prevent hypoxia and metabolic acidosis. Option A) Shivering is a physiological response to cold stress and actually helps generate heat to maintain body temperature, so it is not something to be minimized in this context. Option B) Hyperglycemia is not directly related to cold stress and is more commonly associated with conditions like diabetes or stress response. Option D) Metabolism of fat stores may actually be increased during cold stress as the body tries to generate heat through increased metabolism, so minimizing this process would not be the most appropriate intervention in this situation. Educationally, it is crucial for nurses in maternal newborn care to understand the physiological responses of newborns to stressors like cold exposure. By recognizing the signs of cold stress and knowing the appropriate nursing interventions, nurses can effectively care for newborns and prevent complications associated with thermal instability.