The nurse is assessing a 4-year-old boy whose mother was 40 years old when he was born.

Which finding suggests this child has a genetic disorder?

Choice A rationale

Hypoglycemia, a condition of low blood glucose (normal range 40-60 mg/dL in neonates), is not prevented by phytonadione (vitamin K). This condition is primarily related to inadequate glucose stores or production, often seen in large or small for gestational age infants or those whose mothers had diabetes. Vitamin K is essential for coagulation factor synthesis, not glucose metabolism regulation.

Choice B rationale

Hyperbilirubinemia, characterized by elevated serum unconjugated bilirubin (jaundice), is not prevented by routine vitamin K administration. This condition results from increased breakdown of fetal red blood cells and the neonate's immature liver function being unable to adequately conjugate and excrete bilirubin. Vitamin K does not directly influence bilirubin processing or excretion pathways.

Choice C rationale

Phytonadione (vitamin K) is administered to neonates to prevent Vitamin K Deficiency Bleeding (VKDB), previously known as hemorrhagic disease of the newborn. Vitamin K is crucial for the liver's synthesis of coagulation factors II, VII, IX, and X. Neonates have low vitamin K stores and insufficient gut flora to produce it, making supplementation necessary to prevent life-threatening bleeding.

Choice D rationale

Polycythemia is an abnormally high concentration of red blood cells (hematocrit > 65.

Choice A rationale

While quiet time is important for rest, allowing quiet time alone does not actively facilitate the mutual gaze and physical closeness that are critical for the initial, foundational stages of attachment. The most immediate and important action involves nurse-facilitated interaction that promotes specific bonding behaviors, which is a more direct path to attachment than passive rest.

Choice B rationale

The en face position, where the mother's face and the infant's face are approximately 30 cm apart and on the same vertical plane, is essential because it allows for direct, sustained eye contact. This mutual gaze is recognized as a fundamental element in promoting bonding and attachment by triggering reciprocal behavioral responses that are vital to the early parent-infant relationship formation.

Choice C rationale

Teaching concepts of bonding and attachment is an important nursing function, but it is an educational intervention that is secondary to the immediate, physical, and emotional facilitation of the actual bonding process. The most important action is to create the physical opportunity for bonding through direct sensory interaction immediately after delivery when the infant is in a quiet-alert state.

Choice D rationale

Assisting with breastfeeding is a crucial part of postpartum care and promotes bonding through skin-to-skin contact and physical closeness. However, the most universally important action immediately post-delivery is establishing eye contact and physical proximity (en face, skin-to-skin), as feeding may be delayed or not applicable to all mothers, making the en face position a broader, essential intervention.