The nurse collects client data and determines the newborn is most likely experiencing hypoglycemia as evidenced by which of the following?

Choice A rationale

The shoulder harness straps should be positioned at or slightly below the newborn's shoulders when using a rear-facing car seat. This lower placement is crucial because it directs the force of a frontal collision downward, toward the strong bones of the baby's hips and shoulders, effectively minimizing the stress on the delicate neck and spinal cord. Newborns have proportionally large heads and weak neck muscles.

Choice B rationale

The retainer or chest clip should be placed firmly across the child's mid-chest or armpits (axillary level), not the umbilicus. This specific positioning keeps the harness straps correctly aligned over the shoulders, preventing them from slipping off and ensuring that the child is secured properly, which is vital for maximum protection in the event of a crash.

Choice C rationale

A newborn's car seat should be installed at a semi-reclined angle of approximately 45 degrees (or the angle recommended by the manufacturer, usually indicated by a level or line). A 60-degree angle is too upright and could cause the newborn's head to fall forward, obstructing the airway and increasing the risk of positional asphyxia, especially in a term neonate with underdeveloped neck control.

Choice D rationale

Current safety guidelines recommend that children remain in a rear-facing car seat for as long as possible, until they reach the highest weight or height limit allowed by the car seat manufacturer. The minimum recommendation for switching to forward-facing is typically at 2 years old and having exceeded the rear-facing weight limit, which is usually higher than 15 pounds.

Choice A rationale: Transitional stools indicate progression from meconium to normal infant stool, reflecting adequate feeding and gastrointestinal function. These stools are typically greenish-brown to yellow and appear within the first few days of life. Four stools in one shift suggest active peristalsis and effective bilirubin excretion via feces. This is a positive sign in managing hyperbilirubinemia, as bilirubin is eliminated through the gastrointestinal tract, supporting clinical improvement.

Choice B rationale: Dark yellow urine may suggest concentrated output, potentially indicating suboptimal hydration. While unchanged output may seem stable, the color implies reduced fluid intake or increased bilirubin excretion. In neonates, urine should be pale yellow if hydration is adequate. Persistent dark urine warrants follow-up to assess feeding adequacy and renal function. It is not a definitive sign of expected progression and may signal a need for increased fluid intake.

Choice C rationale: Clear lungs and absence of retractions indicate effective respiratory function and no signs of distress. Retractions are a compensatory mechanism for increased work of breathing, often seen in respiratory compromise. Their absence, along with clear auscultation, suggests normal pulmonary transition and oxygenation. This finding confirms that the newborn is adapting well postnatally, with stable respiratory status and no need for supplemental oxygen or intervention.

Choice D rationale: Softening of the edematous scalp area and presence of ecchymosis suggest resolution of birth trauma, likely a cephalohematoma from vacuum extraction. As blood reabsorbs, firmness decreases and bruising becomes more apparent. This progression is expected and indicates healing. Monitoring is still required for bilirubin levels due to hemolysis, but the physical changes reflect normal recovery from localized trauma without signs of infection or worsening.

Choice E rationale: A total serum bilirubin level of 14.2 mg/dL remains above the normal range (1 to 12 mg/dL) and indicates ongoing hyperbilirubinemia. Although it has decreased from the previous day’s 18.5 mg/dL, it still exceeds the threshold for concern. Continued phototherapy and monitoring are necessary. This value does not yet reflect full resolution, so it cannot be considered a sign of expected progression without further decline.

Choice F rationale: Facial bruising with yellow discoloration suggests ongoing breakdown of red blood cells and bilirubin deposition in the skin. While bruising may resolve over time, the yellowing indicates persistent jaundice. This is a sign of elevated bilirubin and not a marker of improvement. It requires continued phototherapy and monitoring. Therefore, it does not indicate expected progression and warrants follow-up.