A nurse who is caring for a newborn observes signs of respiratory distress, jitteriness, and lethargy. Which of the following actions should the nurse take?

Choice A rationale:

This response would not be appropriate because it provides incorrect information. Breast milk is already present in the mother's breasts during pregnancy, and the newborn's disinterest in eating is likely due to other factors.

Choice B rationale:

This is the best response because it acknowledges the mother's concern and offers a practical solution to help the newborn latch onto the breast properly. Correct latching is crucial for successful breastfeeding, and once the baby latches on correctly, they are more likely to breastfeed effectively.

Choice C rationale:

While it is true that newborns often experience deep sleep phases, attributing the disinterest in eating solely to deep sleep is not accurate. Offering support and guidance for breastfeeding would be more beneficial.

Choice D rationale:

This response oversimplifies the situation and may not address the actual reason for the newborn's disinterest in feeding. It is essential to help the mother with proper techniques rather than just waking up the baby.

Choice A rationale:

Cephalhematoma is the correct answer because it presents as a swelling on the newborn's head confined to one cranial bone and does not cross suture lines. It usually resolves on its own within a few weeks to months but can increase the risk of jaundice due to the breakdown of red blood cells in the hematoma.

Choice B rationale:

Nevus flammeus, also known as a port-wine stain, is a type of vascular birthmark. It presents as a flat, pink, or red mark on the skin and does not involve swelling of the head. This choice is unrelated to the findings described in the question and is therefore incorrect.

Choice C rationale:

Caput succedaneum refers to a diffuse, soft tissue swelling of the scalp that does cross suture lines. It is caused by pressure on the head during delivery, leading to edema and bruising. It typically resolves within a few days after birth.

Choice D rationale:

Molding refers to the shaping of the fetal head during childbirth as it passes through the birth canal. It may cause temporary elongation or molding of the head, but it does not present as a localized swollen area. This choice is not applicable to the findings mentioned in the question and is thus incorrect.