The nurse will conduct what assessment on a newborn at 1 minute and 5 minutes after birth?

Choice A reason: This is not a concerning finding for the nurse. Absence of tears when the infant cries is normal and expected in the first few months of life. The tear ducts and glands are not fully developed yet, and the infant does not produce enough tears to moisten the eyes or overflow the eyelids. The nurse should monitor the infant's hydration and eye health, but should not be alarmed by the absence of tears.

Choice B reason: This is not a concerning finding for the nurse. Presence of vernix caseosa at delivery is normal and expected in newborns, especially those born before 40 weeks of gestation. Vernix caseosa is a white, cheesy substance that covers the skin of the fetus in the womb. It protects the skin from the amniotic fluid and helps with temperature regulation and infection prevention. The nurse should gently wipe off the excess vernix caseosa, but should not try to remove it completely.

Choice C reason: This is not a concerning finding for the nurse. Presence of anterior and posterior fontanels is normal and expected in infants. Fontanels are soft spots on the skull where the bones have not yet fused together. They allow the skull to be flexible and accommodate the growing brain. The nurse should palpate the fontanels gently and assess their size, shape, and tension, but should not be worried by their presence.

Choice D reason: This is the concerning finding for the nurse. Absence of the rooting reflex is abnormal and unexpected in infants. The rooting reflex is an involuntary movement or response that the infant makes when the cheek or mouth is touched. The infant turns the head and opens the mouth, seeking the source of stimulation. The rooting reflex is essential for breastfeeding and feeding in general. The nurse should assess the infant's neurological status and consult with the physician if the rooting reflex is absent.

Choice A reason: This is not the statement that the nurse should prioritize. The adolescent may be experiencing a crush or a rejection, which are common and normal feelings for their age. The nurse should listen and empathize with the adolescent, but also reassure them that there are other people who like and care for them, and that their self-worth is not dependent on one person's opinion.

Choice B reason: This is the statement that the nurse should prioritize. The adolescent may be suffering from an eating disorder or a body image disturbance, which are serious and potentially life-threatening conditions. The nurse should assess the adolescent's weight, height, vital signs, and nutritional intake, and refer them to a specialist if needed. The nurse should also educate the adolescent on the dangers of skipping meals, the benefits of a balanced diet, and the importance of self-acceptance and self-esteem.

Choice C reason: This is not the statement that the nurse should prioritize. The adolescent may be facing a peer pressure or a bullying situation, which are common and challenging issues for their age. The nurse should support and encourage the adolescent to pursue their interests and hobbies, and to stand up for themselves and others. The nurse should also help the adolescent to develop coping skills, such as assertiveness, problem-solving, and stress management.

Choice D reason: This is not the statement that the nurse should prioritize. The adolescent may be experiencing a role conflict or a career dilemma, which are common and normal dilemmas for their age. The nurse should respect and acknowledge the adolescent's preferences and aspirations, and help them to explore their options and potentials. The nurse should also facilitate a communication and understanding between the adolescent and their parent, and help them to reach a compromise or a solution.