A nurse is caring for a newborn delivered by vaginal birth after 3 hours of pushing.
The newborn’s mother asks about the swollen area on her son’s head.
After palpation and identification that the swelling does cross the suture line, which of the following is an appropriate response by the nurse?

Choice A rationale

Hyperbilirubinemia, or high levels of bilirubin in the blood, can occur in newborns of diabetic mothers due to increased red blood cell breakdown. However, it is not the primary concern immediately after birth. The priority is to address conditions that can cause immediate harm, such as hypoglycemia.

Choice B rationale

Hypomagnesemia, or low magnesium levels, can occur in newborns of diabetic mothers, but it is not the most critical issue. Magnesium levels can be monitored and corrected if necessary, but hypoglycemia poses a more immediate threat to the newborn’s health.

Choice C rationale

Hypocalcemia, or low calcium levels, can also occur in newborns of diabetic mothers. While it is important to monitor and manage calcium levels, hypoglycemia is a more urgent concern because it can lead to severe complications if not addressed promptly.

Choice D rationale

Hypoglycemia, or low blood sugar levels, is the most critical concern for newborns of diabetic mothers. These newborns are at high risk for hypoglycemia due to the high levels of insulin they produce in response to their mother’s elevated blood glucose levels during pregnancy. Hypoglycemia can cause serious complications, including seizures and brain damage, if not treated immediately.

Choice A rationale

Erythema toxicum is a common, benign rash seen in newborns. It appears as red patches with small white or yellow pustules in the center. It is not characterized by small raised pearly white spots on the nose and chin.

Choice B rationale

Milia spots are small raised pearly white spots that commonly appear on the nose, chin, and cheeks of newborns. They are caused by trapped keratin and are harmless, usually resolving on their own within a few weeks.

Choice C rationale

Mongolian spots are flat, blue-gray patches commonly found on the lower back and buttocks of newborns, especially those with darker skin. They are not raised and do not appear on the nose and chin.

Choice D rationale

Epstein’s pearls are small white or yellow cysts found on the gums or roof of the mouth in newborns. They are not found on the nose and chin. .