Select all that apply.

A nurse is providing comfort measures to a newborn during an assessment.

What non-pharmacological interventions can the nurse use to soothe the newborn?

The nurse should follow the sequence of 1, 2, 3, 4, 5 when assessing the client’s conjunctiva.This is because the nurse should first apply examination gloves to prevent contamination and infection.Then, the nurse should instruct the client to look up to expose the lower eyelid and conjunctiva.Next, the nurse should place the thumbs below each of the client’s lower eyelids and gently pull the skin down to the top edge of the bony orbital rim.This allows the nurse to inspect the color and condition of the conjunctiva and sclera, noting any color change, swelling, drainage, or lesions.The sclera should be white and the conjunctiva should be pink.

Choice B is wrong because the nurse should not pull down the skin before instructing the client to look up.

This could cause discomfort and injury to the eye.

Choice C is wrong because the nurse should not instruct the client to look up after pulling down the skin.

This could also cause discomfort and injury to the eye.

Choice D is wrong because the nurse should not place the thumbs below each of the client’s lower eyelids before applying examination gloves.

This could introduce infection and irritants to the eye.

Bulging fontanelles.Bulging fontanelles can be a sign of increased intracranial pressure or intracranial and extracranial tumors.This is a potential problem for the newborn’s brain and health and should be evaluated by imaging studies.

Choice A is wrong because sunken fontanelles are usually a sign of dehydration, which is not a problem with the fontanelles themselves, but with the fluid balance of the newborn.

Choice C is wrong because a diamond-shaped anterior fontanelle is normal for a newborn.The anterior fontanelle is the largest and most important for clinical evaluation.It has an average size of 2.1 cm and a median time of closure of 13.8 months.

Choice D is wrong because a triangular posterior fontanelle is also normal for a newborn.The posterior fontanelle is smaller than the anterior one and normally closes by 8 weeks.