Exhibits

A nurse on the labor and delivery unit is continuing to assist in the care of a newborn. Complete the following sentence by using the lists of options. Because the newborn is exhibiting

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the nurse should plan to

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.

Choice A rationale

This describes the glabellar reflex (or blink reflex), where tapping the bridge of the nose or forehead causes a newborn to blink. However, in newborns, repeated tapping will cause the newborn to continue to blink for the first few taps and then eventually stop or habituate, they do not keep their eyes closed after being tapped.

Choice B rationale

This describes the stepping reflex, where the newborn attempts to 'walk' when held upright with their feet touching a surface. The response described, where the legs flex at the knees and hips when pressure is applied to the soles, is the positive support reflex, which involves extending the legs to bear weight, or the crossed extension reflex, but not the expected finding of a simple application of pressure.

Choice C rationale

Touching the newborn's cheek is meant to elicit the rooting reflex. The expected finding is that the newborn will turn their head toward the stimulus and open their mouth, searching for the breast or bottle. Turning the head away from the stimulus indicates an absent or abnormal rooting reflex.

Choice D rationale

This describes the palmar grasp reflex. When the nurse's finger or an object is placed in the newborn's palm, the newborn's fingers will involuntarily flex and tightly curl around the object. This is an expected and primitive reflex in a term newborn and should be bilaterally symmetrical.

Choice A rationale: Flat and open anterior and posterior fontanels are normal findings in a newborn. These soft spots allow for brain growth and accommodate molding during birth. The anterior fontanel typically measures 1–4 cm and closes by 18 months, while the posterior fontanel is smaller and closes by 2 months. Their presence and flatness indicate normal intracranial pressure and hydration status, requiring no follow-up unless bulging or sunken.

Choice B rationale: A firm, edematous area on the scalp that does not cross suture lines suggests a cephalohematoma, which is a subperiosteal hemorrhage. This condition is associated with vacuum-assisted deliveries and increases the risk for hyperbilirubinemia due to breakdown of accumulated red blood cells. Cephalohematomas typically resolve spontaneously but require monitoring for jaundice and anemia. Follow-up is essential to assess bilirubin levels and ensure no complications such as infection or calcification.

Choice C rationale: Fine crackles in the lower lung fields may indicate retained fetal lung fluid or transient tachypnea of the newborn (TTN), especially in late preterm infants. While crackles can be benign in the first hours of life, persistence beyond 24 hours warrants evaluation for respiratory distress or infection. Pulmonary auscultation should be repeated, and oxygenation monitored. Crackles may also signal aspiration or pneumonia, necessitating follow-up to rule out pathology.

Choice D rationale: Acrocyanosis, or bluish discoloration of the hands and feet, is common in the first 24–48 hours of life due to immature peripheral circulation. However, persistence beyond this period may indicate poor perfusion or underlying cardiac issues. In this case, the newborn is on day 3, and continued acrocyanosis requires follow-up to assess for hypoxemia, congenital heart defects, or sepsis. Pulse oximetry and cardiovascular evaluation are warranted.

Choice E rationale: Facial bruising is often associated with birth trauma, especially in vacuum-assisted deliveries. While bruising itself may resolve without intervention, it contributes to increased bilirubin production due to hemolysis of extravasated red blood cells. In a newborn already undergoing phototherapy for hyperbilirubinemia, additional bruising increases the risk for worsening jaundice. Follow-up is necessary to monitor bilirubin levels and ensure adequate phototherapy adherence.

Choice F rationale: Moist, pink, and intact oral mucosa indicates good hydration, oxygenation, and absence of mucosal lesions or infection. This finding reflects normal tissue perfusion and integrity. No follow-up is needed unless signs of dehydration, cyanosis, or oral thrush develop. It confirms that feeding is adequate and systemic circulation is intact.

Choice G rationale: A moist umbilical cord with three vessels—two arteries and one vein—is a normal anatomical finding. The presence of three vessels confirms normal fetal circulation and renal development. Moistness indicates appropriate healing without signs of infection. No follow-up is required unless there is foul odor, purulent discharge, or delayed cord separation.

Choice H rationale: Vernix caseosa is a protective, waxy substance found in skin folds of newborns. It provides antimicrobial properties and prevents skin desiccation. Its presence is normal, especially in preterm or late preterm infants. Vernix is gradually absorbed or removed during bathing. No follow-up is needed unless there are signs of skin breakdown or infection.