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?

C) Cephalhematoma:

A cephalhematoma is a collection of blood between the skull bone and its periosteum. It appears as a raised, bruised area on the scalp and is typically limited by suture lines. Unlike caput succedaneum, which typically resolves within a few days and crosses suture lines, a cephalhematoma does not cross suture lines and may take weeks to months to resolve.

A) Caput succedaneum:

Caput succedaneum is a localized swelling of the soft tissues of the scalp, usually resulting from pressure against the dilating cervix during labor. It typically crosses suture lines and resolves within a few days.

B) Pilonidal dimple:

A pilonidal dimple is a small pit or sinus in the sacrococcygeal area, not related to scalp findings.

D) Molding:

Molding refers to the shaping of the fetal head to adapt to the birth canal during labor and delivery. It is a temporary deformity and does not involve bruising or raised areas on the scalp.

B) Vitamin K injection:

This is correct. Administration of vitamin K injection is a routine practice in newborn care immediately following birth. Newborns have low levels of vitamin K, which is necessary for blood clotting. The injection helps prevent vitamin K deficiency bleeding (VKDB), a serious condition that can occur in newborns.

D) Antibiotic ointment to both eyes:

This is correct. Administration of antibiotic ointment to both eyes is standard practice to prevent neonatal conjunctivitis, which can be caused by organisms such as Neisseria gonorrhoeae or Chlamydia trachomatis acquired during passage through the birth canal. The ointment helps prevent eye infections and is typically administered shortly after birth.

A) Tdap:

Tdap (tetanus, diphtheria, acellular pertussis) vaccine is not routinely administered immediately following birth. It is typically given to pregnant individuals during the third trimester to provide passive immunity to the newborn and protect against pertussis (whooping cough).

C) Haemophilus influenza type b immunization (Hib):

Hib immunization is not typically administered immediately following birth. It is a childhood vaccine that protects against Haemophilus influenzae type b, a bacterial infection that can cause serious illnesses such as meningitis and pneumonia. The vaccine is usually given in a series of doses starting at 2 months of age.

E) Lidocaine gel to the umbilical stump:

Application of lidocaine gel to the umbilical stump is not a standard practice in newborn care immediately following birth. The umbilical cord stump typically dries and separates naturally over the first few weeks of life, and routine application of lidocaine gel is not necessary for its care.