The nurse admits a newborn to the admission nursery and prepares to bathe the baby for the first time after assessing which of the following?

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.

Choice A rationale:

Activating respiratory arrest procedures is not necessary in this situation. The newborn's respiratory rate, although slightly elevated, does not indicate respiratory arrest. Instead, such procedures are reserved for situations where the newborn has stopped breathing or is in acute respiratory distress.

Choice B rationale:

Requesting an order for supplemental oxygen may be premature. The newborn's respiration rate of 44/min, although shallow with periods of apnea, is still within the normal range for a newborn. Providing supplemental oxygen should be considered when the newborn is showing signs of significant respiratory distress or if oxygen saturation levels are low.

Choice C rationale:

The most appropriate action in this scenario is to continue routine monitoring of the newborn's respiratory rate and overall condition. Newborns often exhibit irregular breathing patterns, including periods of apnea, especially in the first few hours after birth. As long as the newborn's color, heart rate, and overall appearance are stable, routine monitoring is appropriate.

Choice D rationale:

There is no need to report the observation to the charge nurse immediately, as the newborn's respiratory rate and pattern fall within the expected range for a 12-hour-old newborn.

Reporting should be considered when there are significant deviations from the norm or if the newborn's condition deteriorates.