A nurse is assisting in the initiation of phototherapy.
Which nursing action is indicated for the newborn?

Choice A rationale: Flat and open anterior and posterior fontanels are normal findings in a newborn. These soft spots allow for brain growth and accommodate molding during birth. The anterior fontanel typically measures 1–4 cm and closes by 18 months, while the posterior fontanel is smaller and closes by 2 months. Their presence and flatness indicate normal intracranial pressure and hydration status, requiring no follow-up unless bulging or sunken.

Choice B rationale: A firm, edematous area on the scalp that does not cross suture lines suggests a cephalohematoma, which is a subperiosteal hemorrhage. This condition is associated with vacuum-assisted deliveries and increases the risk for hyperbilirubinemia due to breakdown of accumulated red blood cells. Cephalohematomas typically resolve spontaneously but require monitoring for jaundice and anemia. Follow-up is essential to assess bilirubin levels and ensure no complications such as infection or calcification.

Choice C rationale: Fine crackles in the lower lung fields may indicate retained fetal lung fluid or transient tachypnea of the newborn (TTN), especially in late preterm infants. While crackles can be benign in the first hours of life, persistence beyond 24 hours warrants evaluation for respiratory distress or infection. Pulmonary auscultation should be repeated, and oxygenation monitored. Crackles may also signal aspiration or pneumonia, necessitating follow-up to rule out pathology.

Choice D rationale: Acrocyanosis, or bluish discoloration of the hands and feet, is common in the first 24–48 hours of life due to immature peripheral circulation. However, persistence beyond this period may indicate poor perfusion or underlying cardiac issues. In this case, the newborn is on day 3, and continued acrocyanosis requires follow-up to assess for hypoxemia, congenital heart defects, or sepsis. Pulse oximetry and cardiovascular evaluation are warranted.

Choice E rationale: Facial bruising is often associated with birth trauma, especially in vacuum-assisted deliveries. While bruising itself may resolve without intervention, it contributes to increased bilirubin production due to hemolysis of extravasated red blood cells. In a newborn already undergoing phototherapy for hyperbilirubinemia, additional bruising increases the risk for worsening jaundice. Follow-up is necessary to monitor bilirubin levels and ensure adequate phototherapy adherence.

Choice F rationale: Moist, pink, and intact oral mucosa indicates good hydration, oxygenation, and absence of mucosal lesions or infection. This finding reflects normal tissue perfusion and integrity. No follow-up is needed unless signs of dehydration, cyanosis, or oral thrush develop. It confirms that feeding is adequate and systemic circulation is intact.

Choice G rationale: A moist umbilical cord with three vessels—two arteries and one vein—is a normal anatomical finding. The presence of three vessels confirms normal fetal circulation and renal development. Moistness indicates appropriate healing without signs of infection. No follow-up is required unless there is foul odor, purulent discharge, or delayed cord separation.

Choice H rationale: Vernix caseosa is a protective, waxy substance found in skin folds of newborns. It provides antimicrobial properties and prevents skin desiccation. Its presence is normal, especially in preterm or late preterm infants. Vernix is gradually absorbed or removed during bathing. No follow-up is needed unless there are signs of skin breakdown or infection.

Choice A rationale

The newborn's weight is an important metric used to assess appropriate growth. While deviations (e.g., small for gestational age or large for gestational age) are risk factors, the mere recording of the weight itself in the EMR is a standard measurement, not inherently a risk factor. It becomes a risk factor only when the measurement falls outside the expected range for the newborn's gestational age.

Choice B rationale

The type of birth (e.g., vaginal, Cesarean section) is a risk factor for complications. Cesarean birth, especially without labor, is associated with an increased risk of transient tachypnea of the newborn (TTN) due to retained fetal lung fluid. Conversely, a prolonged or operative vaginal birth can increase the risk of birth trauma, suggesting the type of birth itself introduces specific complication risks.

Choice C rationale

Apgar scores are a rapid assessment of five physiological signs (Appearance, Pulse, Grimace, Activity, Respiration) at one and five minutes of life. A low Apgar score (typically ≤ 7 at five minutes) is a significant and immediate indicator of neonatal distress and a strong risk factor for long-term neurological complications, necessitating prompt and potentially intensive resuscitation.

Choice D rationale

Gestational age is a primary determinant of neonatal maturity and viability. Preterm birth (less than 37 weeks) is a major risk factor for complications, including respiratory distress syndrome (due to surfactant deficiency), thermoregulation difficulties, and developmental issues. Post-term birth (over 42 weeks) is also a risk for placental insufficiency and meconium aspiration.

Choice E rationale

The recording of heart sounds in the EMR is part of a standard newborn physical assessment. The presence of a normal finding (e.g., regular rhythm, no murmurs) is a sign of health, not a risk factor. An abnormal finding, such as a persistent murmur suggestive of a congenital heart defect, would be the risk factor, but the standard documentation is just a physiological assessment.

Choice F rationale

The newborn's length is a standard anthropometric measurement, assessing overall growth and proportional development. Like weight, recording the length itself is a standard parameter, not a risk factor. It only becomes clinically significant as an indicator of an underlying issue if it is disproportionate or falls significantly outside the expected percentile range for the newborn's gestational age.