A nurse is caring for a newborn 4 hr after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice?

A) It destroys Rh antibodies in mothers who are Rh negative:

This statement is incorrect. Rh(D) Immunoglobulin, commonly known as RhoGAM, does not destroy Rh antibodies in mothers who are Rh negative. Instead, it prevents the mother's immune system from producing Rh antibodies against Rh-positive fetal blood cells.

B) It destroys Rh antibodies in newborns who are Rh positive:

This statement is incorrect. Rh(D) Immunoglobulin does not destroy Rh antibodies in newborns. Its purpose is to prevent the formation of Rh antibodies in Rh-negative mothers, thus protecting future pregnancies from hemolytic disease of the newborn (HDN).

C) It prevents the formation of Rh antibodies in newborns who are Rh positive:

This statement is incorrect. Rh(D) Immunoglobulin does not prevent the formation of Rh antibodies in newborns. It acts by suppressing the mother's immune response to Rh-positive fetal blood cells, thereby preventing the production of Rh antibodies that could harm future pregnancies.

D) It prevents the formation of Rh antibodies in mothers who are Rh negative:

This statement is correct. Rh(D) Immunoglobulin is administered to Rh-negative mothers to prevent the formation of Rh antibodies in response to exposure to Rh-positive fetal blood cells during pregnancy or childbirth. By neutralizing fetal Rh-positive red blood cells in the maternal circulation, it prevents sensitization of the mother's immune system and protects future pregnancies from HDN.

A) "This is a cephalhematoma, which can occur spontaneously":

This is the correct response. A cephalhematoma is a collection of blood between the skull bone and its periosteum and does not cross suture lines. It often develops after vacuum extraction during delivery due to rupture of blood vessels. It is typically benign and resolves on its own over several weeks to months as the blood is reabsorbed by the body. It is important to reassure the mother that this is a common occurrence and usually resolves without intervention.

B) "Mongolian spots can be found on the skin of many newborns":

Mongolian spots are blue-gray birthmarks that commonly appear on the skin of newborns, typically over the buttocks and lower back. They are not related to the swelling on the baby's head and do not cross suture lines.

C) "This is erythema toxicum, which is a transient condition":

Erythema toxicum is a benign rash that appears in many newborns within the first few days of life. It presents as small, yellow or white papules surrounded by erythema and often resolves without treatment within a week. It is not related to the swelling on the baby's head and does not cross suture lines.

D) "A caput succedaneum occurs due to compression of blood vessels and will cross the sutures lines on the baby's head":

While a caput succedaneum is a collection of serosanguinous fluid that crosses suture lines and typically resolves within a few days after birth, it is usually associated with swelling over the presenting part of the fetus during labor, not vacuum extraction. Additionally, caput succedaneum is not typically located on the top of the head, where the swelling from a cephalhematoma would be observed.