A nurse is caring for a newborn and assessing newborn reflexes. To elicit the Moro reflex, the nurse should take which of the following actions?

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.

A) Stop breastfeeding:

Stopping breastfeeding is not recommended as it can lead to engorgement, mastitis, and a decrease in milk supply. Instead, the nurse should encourage the client to continue breastfeeding and offer strategies to reduce nipple soreness.

B) Start breastfeeding with the nipple that is less sore:

Starting breastfeeding with the nipple that is less sore can help reduce discomfort during feeding. This allows the baby to feed more gently on the sore nipple after satisfying initial hunger on the less sore side.

C) Massage the breasts and nipples prior to feeding:

Massaging the breasts and nipples prior to feeding can help stimulate milk flow, soften the breasts, and reduce nipple soreness. It also helps the baby latch on more effectively, reducing discomfort for both the mother and the baby.

D) Apply breast milk to the nipples:

Applying breast milk to the nipples after feeding can help soothe and heal sore nipples. Breast milk has antibacterial properties and can promote healing, making it a natural and safe remedy for nipple soreness.

E) Change the infant's position on the nipples:

Changing the infant's position on the nipples can help prevent further irritation and soreness. Experimenting with different breastfeeding positions, such as the football hold or side-lying position, can distribute pressure more evenly on the nipples and promote better latch and feeding efficiency.