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

Shivering is not a primary concern for newborns as they have limited ability to shiver. Instead, they rely on non-shivering thermogenesis to maintain body temperature.

Choice B rationale

Cold stress is a significant concern for newborns as it can lead to hypothermia, increased oxygen consumption, and metabolic acidosis. Placing a newborn under a radiant heat warmer helps maintain their body temperature and prevent cold stress.

Choice C rationale

Brown fat production is a natural process in newborns that helps generate heat. However, the primary purpose of using a radiant heat warmer is to prevent cold stress, not to stimulate brown fat production.

Choice D rationale

Basal metabolic rate reduction is not the primary concern. The focus is on preventing cold stress and maintaining the newborn’s body temperature.

Choice A rationale

Monitoring blood glucose levels frequently is important for newborns, especially those at risk for hypoglycemia. However, it does not directly prevent jaundice. Jaundice is caused by elevated bilirubin levels, which are not directly related to blood glucose levels.

Choice B rationale

Beginning phototherapy immediately is a treatment for jaundice, not a preventive measure. Phototherapy is used to reduce high bilirubin levels in newborns who already have jaundice.

Choice C rationale

Initiating early feeding is an effective way to prevent jaundice in newborns. Early feeding helps promote regular bowel movements, which aids in the excretion of bilirubin from the body, thereby reducing the risk of jaundice.

Choice D rationale

Preparing for a blood transfusion is a treatment for severe jaundice, not a preventive measure. Blood transfusions are used in cases of extreme hyperbilirubinemia that do not respond to other treatments.