Temperature 36.2°C axillary on radiant warmer.

Choice A rationale:

Assessing whether it has been two hours since the baby's last feeding is important, but it is not directly related to preparing for the first bath. This information is more relevant for ensuring the baby is ready for feeding.

Choice B rationale:

The nurse should assess the baby's temperature before bathing to ensure it is within the normal range. A temperature of 36.2°C axillary on a radiant warmer is within the normal range for a newborn (normal axillary temperature ranges from 36.5°C to 37.5°C). Bathing a baby with a stable and appropriate temperature helps prevent hypothermia and maintains their well-being during the bathing process.

Choice C rationale:

Drying of the umbilical cord is not a crucial factor to consider before the first bath. While it is essential to keep the umbilical cord dry to prevent infection, it does not determine the baby's readiness for a bath.

Choice D rationale:

While maintaining a stable temperature for two hours is essential, it is not the most critical factor to consider before the first bath. The baby's axillary temperature assessment is a more direct and specific indicator of their readiness for a bath.

Back to sleep.

Choice A rationale:

Placing a baby on their back to sleep is the most effective way to prevent flat spots on the back of their head. This sleeping position, recommended by pediatric experts, helps reduce the risk of sudden infant death syndrome (SIDS) while also minimizing pressure on any one part of the baby's head, thus decreasing the likelihood of developing flat spots.

Choice B rationale:

Taking the baby for walks does not directly address the prevention of flat spots on the back of the head. Although it is beneficial for the baby's overall well-being, it does not specifically address the positional issue that leads to flat spots.

Choice C rationale:

Keeping the baby awake most of the day is not a suitable solution, as it may lead to sleep deprivation and hinder the baby's development. Adequate sleep is essential for a baby's growth and development.

Choice D rationale:

Tummy time is a valuable activity to promote the baby's neck and upper body strength. While it can indirectly contribute to preventing flat spots by encouraging different head positions, it is not as effective as placing the baby on their back to sleep.

"This is a caput succedaneum, which is a collection of fluid from the pressure of the vacuum extractor.”.

Choice A rationale:

A Mongolian spot is a benign, flat, bluish-gray pigmented area often found on the sacral or gluteal area of some newborns with darker skin tones. It is not related to the swelling on the newborn's head caused by vacuum extraction.

Choice B rationale:

A caput succedaneum is a localized swelling on the baby's scalp that occurs due to pressure from the vacuum extractor during delivery. It is typically soft and may cross the suture lines. This explanation accurately describes the swelling the baby has on his head.

Choice C rationale:

Erythema toxicum is a common rash that appears as small red bumps with white or yellow centers. It is a benign and self-resolving condition that does not cause swelling on the head or involve the suture lines.

Choice D rationale:

A cephalhematoma is a collection of blood between the skull and the periosteum that does not cross the suture lines. It is caused by trauma during birth and may take weeks to months to resolve. This does not match the description of the swelling caused by vacuum extraction.

The nurse's priority concern is that the infant is overstimulated.

Choice A rationale:

Metabolic alkalosis and Choice B rationale:

Metabolic acidosis are not relevant concerns in this scenario, as there is no information provided to suggest any disturbances in the infant's acid-base balance. The symptoms described by the mother, such as crying, kicking, and tiredness, are more indicative of an emotional response rather than a metabolic disorder.

Choice C rationale:

While hunger could be a valid concern for the infant, it is not the nurse's priority concern in this situation. The infant's symptoms of crying, kicking, and tiredness indicate a need for soothing and comforting, which suggests overstimulation is the primary concern.

Choice D rationale:

The infant being overstimulated is the correct answer. The symptoms of crying, kicking, and tiredness, along with the cold room, suggest that the infant may be overwhelmed by sensory input, leading to overstimulation. The nurse's priority should be to provide a calm and soothing environment for the infant.

"My baby will be placed under special lights if the test is elevated.”.

Choice A rationale:

This statement indicates a need for further teaching. Phenylketonuria (PKU) is a metabolic disorder that leads to the accumulation of phenylalanine in the body. If the PKU test is elevated, it means that the baby has high levels of phenylalanine, and immediate dietary intervention is required. The parent's statement about special lights suggests a confusion with jaundice treatment, which is not related to PKU.

Choice B rationale:

This statement is accurate. Before the PKU test is done, the baby needs to consume formula or breast milk to ensure accurate test results.

Choice C rationale:

This statement is also accurate. PKU is a genetic disorder that can be managed with a special diet low in phenylalanine. By adhering to the prescribed diet, the harmful effects of PKU can be minimized.

Choice D rationale:

This statement is accurate. It is common for the PKU test to be repeated at the 2-week check- up to confirm the initial results and ensure early detection and management of PKU if present.

The nurse should use the lower ribcage border to measure chest circumference.

Choice A rationale:

The sternal notch is not an appropriate landmark for measuring chest circumference. It is a notch at the top of the sternum and not indicative of chest circumference.

Choice B rationale:

The nipple line is not a suitable landmark for measuring chest circumference as it does not provide a consistent and standardized point of measurement.

Choice C rationale:

The lower ribcage border is the correct answer. Measuring chest circumference at this landmark ensures consistency and accuracy in the measurement, which is important for monitoring the growth and development of the newborn.

Choice D rationale:

The axillae (armpits) are not used as a landmark for measuring chest circumference. It is not a standardized anatomical point for this purpose.

Rooting. Choice A rationale:

The Moro reflex is a startle reflex characterized by the infant's sudden extension and abduction of the arms in response to a loud noise or sudden movement. It is not involved in the initiation of sucking and is unrelated to breastfeeding.

Choice B rationale:

The rooting reflex is a crucial reflex that helps initiate sucking in newborns. When the infant's cheek is stroked or touched, they will turn their head toward the stimulus and open their mouth, preparing for feeding. This reflex helps the infant find the mother's nipple and begin breastfeeding effectively.

Choice C rationale:

The stepping reflex is a primitive reflex observed in newborns when held upright with their feet touching a solid surface. The baby will make stepping movements, mimicking walking. However, this reflex is not related to the initiation of sucking and breastfeeding.

Choice D rationale:

The Babinski reflex is a reflex in which the big toe extends upward and the other toes fan out when the sole of the foot is stimulated. This reflex is present in newborns and disappears as the child grows older. It is not involved in the initiation of sucking.

Fetal circulation continues until after the stress of labor.

Choice A rationale:

Fetal circulation undergoes significant changes at birth. It becomes ineffective as the transition from intrauterine to extrauterine life occurs. The foramen ovale and ductus arteriosus, which allow blood to bypass certain fetal circulatory pathways, close as the baby breathes for the first time.

Choice B rationale:

Fetal circulation does not continue until red blood cells are broken down. Red blood cells in a fetus have a shorter lifespan than those in adults and are continually replaced throughout gestation. However, their breakdown is not the reason for the changes in fetal circulation.

Choice C rationale:

The correct answer. Fetal circulation continues until after the stress of labor. During labor, the baby experiences increased stress and pressure, which helps trigger various physiological changes, including the closure of specific fetal circulatory shunts.

Choice D rationale:

Fetal circulation does not continue until adulthood. As mentioned earlier, the transition from fetal to adult circulation occurs during and after birth, with the closure of specific fetal shunts and the establishment of a fully functional adult circulatory system.

A blood glucose fingerstick of 40 mg/dL for an infant who is 1- hour old.

Choice A rationale:

This finding should be notified to the charge nurse immediately because a blood glucose level of 40 mg/dL in a 1-hour-old infant is significantly lower than the normal range. Hypoglycemia in newborns can lead to serious complications, including neurological issues. Normal blood glucose levels in newborns are typically around 45-90 mg/dL.

Choice B rationale:

A hematocrit of 60% in an 8-hour-old infant may be considered relatively high, but this is a normal finding in newborns. Hematocrit levels can be higher in neonates due to their unique physiological adaptation to extrauterine life.

Choice C rationale:

Jaundice in a 4-hour-old infant is a common occurrence and is not typically a cause for immediate concern. Physiological jaundice often appears after 24 hours of birth and resolves on its own.

Choice D rationale:

Acrocyanosis, bluish discoloration of the hands and feet, is a normal finding in newborns and is not considered a cause for concern. It occurs due to the immature peripheral circulation and typically resolves within a few days.

Choice A rationale:

The newborn reflex called "rooting”. is characterized by turning the head and opening the mouth when the cheek or mouth area is touched. This reflex helps the newborn find the mother's breast for feeding.

Choice B rationale:

"Stepping”. is a newborn reflex where they make stepping movements when held upright with their feet touching a solid surface. This reflex is present at birth but tends to disappear after a few weeks.

Choice C rationale:

The "Moro”. reflex is also known as the startle reflex. It is elicited by a sudden loss of support or loud noise, causing the newborn to throw their arms and legs out and then bring them back in. This reflex usually disappears around 3 to 4 months of age.

Choice D rationale:

The "Babinski”. reflex is characterized by the extension of the big toe and fanning of the other toes when the sole of the foot is stroked. This reflex is present in newborns and should disappear by around 12 months of age.

Choice E rationale:

"Running”. is not a recognized newborn reflex. There is no reflex with this name related to newborns.

Choice F rationale:

The "gag”. reflex is present in newborns and helps protect the airway by causing a gagging response when the back of the throat is stimulated.