The nursing assessment of an infant reveals expiratory grunting, substernal retractions, and a temperature of 99° F (32.2° C). What is the first nursing action?

Correct Answer: B

Rationale: In this scenario, the correct first nursing action is B) Begin administration of 40% humidified oxygen via hood. This choice is the most appropriate because the infant is displaying signs of respiratory distress, indicated by expiratory grunting and substernal retractions, which require immediate intervention to support adequate oxygenation. Option A, placing the infant in Trendelenburg position, is incorrect because this position is not recommended for infants with respiratory distress as it can worsen their condition by increasing pressure on the chest and compromising respiratory effort. Option C, increasing the temperature of the environment, is not the priority in this situation as the infant's respiratory distress needs to be addressed first. Option D, performing a complete assessment for congenital anomalies, is important but not the immediate priority when the infant is showing signs of respiratory distress. Addressing the respiratory distress is crucial to ensure the infant's oxygenation needs are met. In an educational context, understanding the signs of respiratory distress in infants and knowing the appropriate interventions is essential for nurses working in maternal and reproductive health. Recognizing these signs early and knowing the appropriate actions to take can prevent further complications and improve outcomes for infants in distress.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Physiologic jaundice. Physiologic jaundice is a common condition in newborns due to the breakdown of red blood cells and the liver's immaturity in processing bilirubin. Option B) Hemolytic disease of the newborn is incorrect because this condition results from Rh incompatibility between the mother and baby's blood types, leading to excessive breakdown of red blood cells. Option C) Erythroblastosis fetalis, another term for hemolytic disease of the newborn, is also incorrect due to the mismatch in blood types between the mother and baby, causing the baby to produce antibodies against its own red blood cells. Option D) Sepsis is incorrect as it refers to a severe infection in the baby's bloodstream, which can cause jaundice but is not the primary cause in this case. In an educational context, understanding the different causes of neonatal jaundice is crucial for nurses to provide appropriate care and interventions. Physiologic jaundice is a common occurrence that usually resolves without treatment, while other causes may require specific management strategies to prevent complications. Nurses must be able to differentiate between these causes to ensure the well-being of newborns.

Correct Answer: B

Rationale: The most appropriate response by the nurse is option B) It is molding caused by the pressure during birth and will disappear in a few days. This is the correct answer because newborns often have a misshapen or elongated head after birth due to the pressure exerted on the skull during the passage through the birth canal. This condition, known as molding, is a normal and temporary phenomenon. It typically resolves within a few days as the baby's head returns to a more rounded shape. Option A is incorrect because dismissing the mother's concerns without providing information could lead to increased anxiety and uncertainty. Option C is incorrect as there is no need for a diagnostic scan unless there are other concerning symptoms present. Option D is incorrect as it describes a cephalohematoma, which is a different condition involving blood accumulation under the scalp and does not apply to the described situation of a "cone head" appearance. In an educational context, it is important for nurses to reassure parents about common newborn characteristics and variations to alleviate unnecessary anxiety. Understanding the normal physiological changes that occur in newborns can help parents feel more confident in caring for their baby and promote a positive parent-child relationship. Educating parents on what to expect in the immediate postpartum period can enhance their overall experience and adjustment to parenthood.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Acrocyanosis. Acrocyanosis is a condition commonly seen in newborns where there is a bluish discoloration of the hands and feet due to peripheral vasoconstriction. It is a normal finding in newborns and typically does not indicate any underlying health issues. Option A) Potential for respiratory distress is incorrect because there are no signs of respiratory distress mentioned in the scenario. Option B) Poor oxygenation is also incorrect as acrocyanosis does not necessarily indicate poor oxygenation. Option C) Cold stress is not the correct answer in this case as acrocyanosis is not solely caused by cold stress. Educationally, it is important for nurses to be familiar with normal variations in newborn assessments to differentiate between what is normal and what may require further investigation or intervention. Understanding acrocyanosis as a benign condition helps nurses provide appropriate care without unnecessary alarm or intervention. This knowledge contributes to accurate documentation and effective communication within the healthcare team.

Correct Answer: D

Rationale: The correct answer is option D: "I'm sure you have discussed this with your doctor, but let's review the benefits and risks of circumcision." This response is the most appropriate because it acknowledges the parents' previous discussions with their doctor while also promoting an informed decision-making process through an open dialogue about the benefits and risks of circumcision. Option A is incorrect because although some studies suggest a reduced risk of penile cancer with circumcision, the evidence is not strong enough to recommend routine circumcision solely for this reason. Option B is not the best choice as it does not provide the parents with valuable information or guidance to make an informed decision. Option C is incorrect because it misrepresents the current stance of the American Academy of Pediatrics, which recognizes that the decision to circumcise is a personal one and should be made by the parents after receiving accurate and unbiased information. In an educational context, it is crucial for nurses to approach discussions about circumcision with sensitivity, respect, and a focus on providing evidence-based information to empower parents to make informed decisions about their child's health. By engaging in open and non-judgmental conversations, nurses can support parents in navigating the complex decision-making process surrounding circumcision, ultimately promoting the well-being of both the newborn and the family.