Which physical signs could indicate a risk for hyperbilirubinemia?

Choice A reason:

Drying the newborn's skin thoroughly is the nurse's priority after assuring a patent airway because it reduces evaporative heat loss by the newborn and prevents cold stress. Cold stress can lead to hypoxia, hypoglycemia, acidosis, and increased bilirubin levels. Drying the newborn also stimulates breathing and crying, which are signs of a healthy newborn.

Choice B reason:

Administering phytonadione IM is not the nurse's priority because it is not an immediate life-saving intervention. Phytonadione is given to prevent hemorrhagic disease of the newborn, which is caused by vitamin K deficiency. However, this condition usually occurs after the first day of life, so administering phytonadione can be delayed until after the initial assessment and stabilization of the newborn.

Choice C reason:

Documenting the Apgar score is not the nurse's priority because it is not an action that directly affects the newborn's well-being. The Apgar score is a tool to assess the newborn's condition at 1 and 5 minutes after birth based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. The Apgar score can help guide the nurse's interventions, but it is not more important than providing care to the newborn.

Choice D reason:

Applying identification bands is not the nurse's priority because it is not an urgent or essential action. Identification bands are used to ensure the safety and security of the newborn and prevent errors or mix-ups. However, applying identification bands can be done after the newborn is dried, warmed, and assessed for any problems.

Choice A reason:

Holding the newborn vertically, allowing one foot to touch the crib surface, will elicit the stepping reflex, not the Moro reflex. The stepping reflex is when the newborn makes stepping movements when held upright with one foot touching a flat surface.

Choice B reason:

Turning the newborn's head quickly to one side will elicit the tonic neck reflex, not the Moro reflex. The tonic neck reflex is when the newborn assumes a "fencing”. position, with the arm and leg extended on the side to which the head is turned and the opposite arm and leg flexed.

Choice C reason:

Performing a sharp hand clap near the infant will elicit the Moro reflex, also known as the startle reflex. The Moro reflex is when the newborn responds to a sudden loss of support or a loud noise by extending and abducting the arms, spreading the fingers, and then bringing the arms together and crying.

Choice D reason:

Placing a finger at the base of the newborn's toes will elicit the Babinski reflex, not the Moro reflex. The Babinski reflex is when the newborn fans out the toes and dorsiflexes the big toe when the sole of the foot is stroked.