A nurse is caring for a newborn immediately following birth and notes a large amount of mucus in the newborn's mouth and nose. Identify the sequence the nurse should follow when performing suction with a bulb syringe.

(Arrange the steps, placing them in the selected order of performance. Use all the steps.)

Hemolytic disease of the newborn (HDN) is a condition that occurs when there is an incompatibility between the blood types of the mother and the baby. It causes the mother's immune system to produce antibodies that attack and destroy the baby's red blood cells, leading to anemia, jaundice, organ enlargement, and other complications¹.

One of the most common causes of HDN is Rh incompatibility. This happens when the mother is Rh negative and the baby is Rh positive. The Rh factor is a protein that can be present or absent on the surface of red blood cells. People who have the protein are Rh positive and people who do not have it are Rh negative

Rh incompatibility can cause HDN when the baby's Rh positive blood cells cross the placenta and enter the mother's bloodstream. This can happen during delivery, miscarriage, abortion, or invasive prenatal testing. The mother's immune system recognizes the baby's blood cells as foreign and produces antibodies against them. These antibodies can cross back to the baby's bloodstream and attack the baby's red blood cells, causing hemolysis (breakdown) and anemia².

HDN due to Rh incompatibility usually does not affect the first pregnancy, because the mother has not been exposed to Rh positive blood before and has not developed antibodies yet. However, it can affect subsequent pregnancies with Rh positive babies, because the mother has become sensitized and has antibodies ready to attack².

The other options are not causes of HDN:

a) The mother and the father are both Rh negative. This is not a cause of HDN because both parents have the same Rh factor and there is no incompatibility between them. The baby will also be Rh negative and will not trigger an immune response from the mother².

b) The mother and the father are both Rh positive. This is not a cause of HDN because both parents have the same Rh factor and there is no incompatibility between them. The baby will also be Rh positive and will not trigger an immune response from the mother².

c) The mother is Rh positive and the father is Rh negative. This is not a cause of HDN because the mother has a dominant Rh factor and will not produce antibodies against it. The baby will either be Rh positive or Rh negative, depending on whether they inherit the father's gene or not. In either case, the baby's blood type will not trigger an immune response from the mother².

Breast development is a normal part of fetal and neonatal growth. It occurs in stages, starting before birth and continuing during puberty and adulthood. Breast development is influenced by hormones, such as estrogen and progesterone, that are produced by the ovaries or the placenta¹².
Breast development in newborns can vary depending on the gestational age, sex, weight, and exposure to maternal hormones. Some newborns may have palpable breast tissue at birth, while others may develop it later in the first weeks of life. Some newborns may also secrete milk from their breasts, which is called witch's milk or neonatal galactorrhea. This is a harmless and temporary phenomenon that usually resolves within a few weeks without treatment³⁴.
The degree of breast development in newborns can be assessed by using a scoring system that ranges from 0 to 5, based on the size of the areola (the dark area around the nipple) and the presence of a bud (a small lump of glandular tissue under the areola). The scoring system is as follows³:
- Score 0: No breast tissue; flat areola with no bud
- Score 1: Breast tissue < 5 mm; flat areola with no bud
- Score 2: Breast tissue 5 to 10 mm; flat areola with no bud
- Score 3: Breast tissue > 10 mm; raised areola with no bud
- Score 4: Breast tissue > 10 mm; raised areola with bud
- Score 5: Breast tissue > 10 mm; raised areola with large bud
The average score for term newborns is 2.5 for girls and 2.0 for boys. The score tends to be higher for heavier babies and lower for lighter babies. The score also tends to be higher for babies who were exposed to higher levels of maternal hormones during pregnancy, such as those whose mothers had diabetes, preeclampsia, or multiple gestation³⁴.
A score of 0 indicates that there is no breast tissue at all, and the areola is flat with no bud. This finding can indicate preterm gestational age, as breast development usually starts before birth and progresses with increasing gestational age. Preterm newborns may have delayed or incomplete breast development due to insufficient exposure to maternal hormones or immature development of their own hormonal system³⁵.
Therefore, the nurse should identify this finding as indicating preterm gestational age and monitor the newborn for any other signs of prematurity, such as low birth weight, small head size, thin skin, low body temperature, respiratory distress, or feeding difficulties. The nurse should also provide appropriate care and support to the newborn and the parents according to the hospital protocol³⁵.

- b) Ambiguous secondary sex characteristics are physical features that do not clearly match the typical male or female pattern, such as genitalia, hair distribution, or voice pitch. They can be caused by genetic disorders, hormonal imbalances, or environmental influences. Ambiguous secondary sex characteristics do not affect breast development in newborns, as breast tissue is present in both sexes and is influenced by maternal hormones rather than sex hormones¹ .
- c) Decreased maternal hormones during pregnancy can affect breast development in newborns, but not in the way described. Decreased maternal hormones during pregnancy can cause lower breast scores in newborns, as they may have less stimulation of their breast tissue from the placenta. However, this does not mean that they have no breast tissue at all or a flat areola with no bud. They may still have some degree of breast development depending on their gestational age, sex, weight, and exposure to their own hormones³⁴.
- d) Congenital anomaly is a term that refers to any structural or functional abnormality that is present at birth. Congenital anomalies can affect any part of the body and can have various causes, such as genetic mutations, chromosomal abnormalities, infections, drugs, or environmental factors. Congenital anomalies can affect breast development in newborns, but not in the way described. Congenital anomalies that affect breast development in newborns usually cause abnormal or absent nipples or breasts, such as nipple hypoplasia (underdeveloped nipples), athelia (absence of nipples), amastia (absence of breasts), or polymastia (extra breasts). These anomalies do not cause a flat areola with no bud .