Upon discharge, parents of a newborn reveal their plans to take their newborn to the beach with them on a vacation when the newborn is 3 months old. Which statement by the nurse is the most appropriate?

Correct Answer: D

Rationale: The correct answer is D because newborns have delicate skin that is highly susceptible to sunburn and heat-related issues. Placing the newborn in lightweight clothing and in the shade helps protect their sensitive skin from harmful UV rays. This approach minimizes the risk of sunburn and overheating. A is incorrect because newborns should not be exposed to direct sunlight for prolonged periods. B is inappropriate as it is important for newborns to be with their parents for bonding and care. C is incorrect as sunscreen is not recommended for infants under 6 months of age due to potential skin irritation and absorption concerns.

Correct Answer: C

Rationale: The correct answer is C: erythema toxicum. This rash is characterized by red macules with small white papules in the center. Erythema toxicum is a common benign rash in newborns, usually appearing in the first few days of life. Milia (A) are tiny white bumps on the skin, Mongolian spots (B) are blue-gray birthmarks, and Café-au-lait spots (D) are flat, light brown spots. In this case, the description of a maculopapular rash with a red base and a small white papule matches the characteristics of erythema toxicum, making it the correct choice.

Correct Answer: B

Rationale: The correct answer is B because placing a blanket over the scale before weighing the infant helps prevent unnecessary heat loss by keeping the baby warm during the process. This action maintains the baby's body temperature and reduces the risk of hypothermia. A: Maintaining room temperature at 21°C may not be sufficient to prevent heat loss during specific procedures. C: Taking rectal temperature every hour is not necessary and may expose the baby to unnecessary heat loss. D: Undressing the infant completely for assessments can lead to rapid heat loss and should be avoided to maintain the baby's body temperature.

Correct Answer: C

Rationale: The correct answer is C: Pause in breathing lasting 20 seconds. This finding indicates a potential apnea episode in the newborn, which requires immediate attention to prevent further complications like hypoxia. The pause in breathing lasting 20 seconds exceeds the normal range for apnea in newborns, typically defined as a pause lasting more than 15 seconds. Prompt action is necessary to assess and address the underlying cause of the apnea episode. Choice A (Respiratory rate of 50 breaths per minute) is within the normal range for newborns (30-60 breaths per minute) and does not require immediate action. Choice B (Cyanosis of the extremities) may indicate poor circulation but is not as urgent as a prolonged pause in breathing. Choice D (Pause in breathing for 15 seconds followed by rapid respirations) is incorrect as it does not meet the criteria for apnea in newborns and does not require immediate action.

Correct Answer: A

Rationale: The correct answer is A: Respiratory. Retractions, nasal flaring, and tachypnea are signs of respiratory distress in a newborn. The nurse should focus on the respiratory system to assess the baby's breathing, lung sounds, oxygen saturation, and overall respiratory status. This is crucial for identifying any potential respiratory issues and providing prompt interventions. Choices B, C, and D are incorrect because the symptoms described are specific to respiratory distress and do not indicate cardiovascular, gastrointestinal, or musculoskeletal issues. Focusing on these systems would not address the immediate concern of respiratory distress in the newborn.