A. No bowel movement within 12 hours: While concerning, delayed stooling can occur in preterm infants and is not as urgent without additional symptoms like distension or bilious vomiting.
B. Small regurgitation of formula: Regurgitation is a common finding in preterm infants and typically not alarming unless persistent or associated with other symptoms like aspiration.
C. Abdominal distension: This finding may indicate necrotizing enterocolitis (NEC) or an obstruction, both of which are serious conditions requiring prompt medical attention.
D. Uncoordinated suck: This is expected in preterm infants due to immaturity and does not require immediate reporting.

A. Feed the infant at least 1 ounce of formula: Feeding may help if the baby is hungry, but it is not the first action in managing symptoms of NAS.
B. Collect a sterile urine specimen: This is an important step for diagnosing NAS but is not the immediate action to calm the infant.
C. Swaddle the infant with hands near its mouth: These symptoms are consistent with neonatal abstinence syndrome (NAS). Comfort measures such as swaddling and non-nutritive sucking are prioritized to soothe the infant.
D. Move the infant into a brightly lit area: A quiet, dim environment is better for soothing an overstimulated baby, so this action would be counterproductive.

Respiratory Status: The newborn is exhibiting signs of respiratory distress, including a respiratory rate of 100/min, grunting, nasal flaring, and substernal retractions. These findings indicate compromised respiratory function, which requires immediate attention to prevent hypoxemia or respiratory failure. The diffuse radiopaque areas on the chest x-ray suggest a condition like transient tachypnea of the newborn (TTN) or respiratory distress syndrome (RDS), common in low-birth-weight infants.

Temperature: After stabilizing the respiratory status, addressing the newborn’s temperature is important. The temperature of 36.3°C (97.3°F) indicates mild hypothermia, which can further compromise respiratory function and glucose metabolism if not corrected. Warming the infant with skin-to-skin contact or using a radiant warmer is necessary to maintain thermoregulation.

A. Elevated hemoglobin and bilirubin: These findings are more consistent with jaundice or polycythemia, not sepsis.
B. Acrocyanosis and unstable thermoregulation: Acrocyanosis is normal in newborns; thermoregulation issues are concerning but nonspecific for sepsis.
C. Generalized mottling and uncoordinated suck: These may occur in sepsis but are less specific compared to lethargy and pallor.
D. Lethargy and pallor: These are classic signs of neonatal sepsis, a potentially life-threatening condition requiring immediate intervention.

Prolactin: This hormone, released by the anterior pituitary gland, stimulates the alveolar cells in the mammary glands to produce breast milk. Prolactin levels increase significantly after birth in response to the infant's suckling.

Oxytocin: Released by the posterior pituitary gland, oxytocin triggers the contraction of the myoepithelial cells surrounding the alveoli, causing milk to be ejected from the ducts, a process known as the let-down reflex.

A. Ice packs after feeding can help reduce swelling and provide comfort for engorgement.

B. Applying hot packs during breastfeeding can increase blood flow and potentially make engorgement worse. Cold packs or ice are typically recommended after breastfeeding to reduce swelling and discomfort from engorgement.

C. Cabbage leaves are sometimes used as a natural remedy for engorgement, as they can help reduce inflammation and discomfort.

D. Breastfeeding every 2 hours is a recommended practice to help relieve engorgement and establish milk supply.

A. Tachycardia: A compensatory response to cold stress as the infant tries to generate heat.
B. Shivering: Rare in newborns due to immature thermoregulation; not a common finding.
C. Hypoglycemia: Cold stress increases glucose consumption, risking hypoglycemia.
D. Lethargy: A late sign indicating worsening cold stress and potential hypothermia.
E. Hypertonia: Unrelated to cold stress, which more commonly causes hypotonia.

A. The Ballard tool does not assess behavioral maturity directly.
B. The reflexes are part of the neuromuscular system, but the tool assesses both neuromuscular and physical maturity.
C. The Ballard assessment tool evaluates both neuromuscular maturity (such as posture, square window sign, arm recoil) and physical maturity (such as skin, ear form, breast tissue) in neonates to assess gestational age.
D. Reflexes are part of neuromuscular maturity, but the tool combines both neuromuscular and physical components.

A. The nurse should dry the neonate immediately after birth to prevent heat loss, as newborns are at risk for hypothermia.
B. APGAR scoring is typically done 1 and 5 minutes after birth, not every 30 minutes during the 3rd stage of labor.
C. The neonatal assessment is usually performed after the delivery of the placenta, not during the 3rd stage of labor.
D. Blood samples for blood type are typically obtained after the newborn has stabilized, not during the 3rd stage of labor.

A. The basal metabolic rate may increase as a result of cold stress, but the primary purpose of the warmer is to prevent cold stress.
B. Newborns are at risk of cold stress because they have a large body surface area and limited ability to regulate body temperature. A radiant warmer is used to help maintain the newborn’s body temperature and prevent cold stress.
C. Newborns do not typically shiver to generate heat. They rely on mechanisms such as non-shivering thermogenesis (use of brown fat).
D. Brown fat is used for heat production, but the goal of the radiant warmer is to prevent cold stress, not directly stimulate brown fat production.