A newborn, who is 4 hours old, presents with the following symptoms: axillary temperature of 96.8° F (35.8° C), heart rate of 150 beats/minute with a soft murmur, irregular respiratory rate at 64 breaths/minute, jitteriness, hypotonicity, and a weak cry.
What should the nurse do based on these findings?

Choice A rationale

In the context of a fetus weighing an estimated 8 pounds at 36-weeks gestation in a client with gestational diabetes, an amniocentesis would most likely be performed to assess the maturity of the fetal lungs. This is because babies of mothers with gestational diabetes are at risk for

respiratory distress syndrome if delivered early, and the baby’s size may indicate that early delivery could be beneficial.

Choice B rationale

While amniocentesis can be used to detect neural tube defects, these are usually diagnosed earlier in pregnancy. Furthermore, there is no specific link between gestational diabetes, fetal weight, and neural tube defects that would make this the primary reason for performing an amniocentesis in this scenario.

Choice C rationale

Amniocentesis can be used to detect chromosomal abnormalities. However, these are typically screened for earlier in pregnancy and would not be directly related to the mother’s gestational diabetes or the estimated fetal weight.

Choice D rationale

The gender of the fetus can be determined through amniocentesis, but it can also be determined more simply through ultrasound. Therefore, it is unlikely that an amniocentesis would be performed for this purpose, especially considering the mother’s gestational diabetes and the baby’s size.

Choice A rationale

Poor appetite can be a symptom of many neonatal conditions, but it's not the most common complication specifically associated with cephalhematoma.

Choice B rationale

Cephalhematomas are caused by the rupture of blood vessels between the skull and periosteum, resulting in a blood collection. The breakdown of red blood cells in this trapped blood can lead to the release of bilirubin, increasing an infant's risk for hyperbilirubinemia and jaundice.

Choice C rationale

Hypoglycemia is a potential concern in neonates but is not directly related to cephalhematoma.

Choice D rationale

While brain damage is a serious potential complication in cases of severe skull trauma, it's not typically associated with cephalhematoma alone. Cephalhematomas usually resolve on their own without long-term consequences.