A new parent asks the nurse about an area of swelling on the baby’s head near the posterior fontanel that lies across the suture line. How should the nurse respond?

“That is called caput succedaneum. It will have to be drained.”.

“That is called a cephalhematoma. It can cause jaundice as it is absorbed.”.

“That is called a cephalhematoma. It will cause no problems.”.

“That is called caput succedaneum. It will absorb and cause no problems.”.

A couple who plan to use in-vitro fertilization with donated sperm.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Caput succedaneum is a benign swelling of the soft tissues of the scalp that crosses suture lines and does not require drainage.

Choice B rationale

Cephalhematoma is a collection of blood between the skull and periosteum that does not cross suture lines; it may contribute to jaundice as it is reabsorbed by the body.

Choice C rationale

While cephalhematoma usually resolves without intervention, it is important to monitor for potential complications, including jaundice, due to the breakdown of red blood cells.

Choice D rationale

Caput succedaneum typically resolves on its own without intervention, as the fluid is gradually absorbed by the body over time.

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Correct Answer is A

Explanation

Choice A rationale

A blood glucose level should be obtained first to determine if hypoglycemia is the cause of the infant's jitteriness, which is common in large-for-gestational-age infants of diabetic mothers.

Choice B rationale

Feeding glucose water might help if the infant is hypoglycemic, but confirmation of blood glucose levels is necessary before administration to avoid hyperglycemia.

Choice C rationale

Administering oxygen is indicated if there are signs of respiratory distress or cyanosis, which is not the first consideration in a jittery infant.

Choice D rationale

Decreasing environmental stimuli can be helpful for a jittery infant, but assessing and managing potential hypoglycemia is the priority action.

A. Improve insufficient dietary intake. B. Stimulate the immune system. C. Prevent hemorrhagic disorders. D. Help an immature liver.

Correct Answer is C

Explanation

Choice A rationale

Phytonadione (vitamin K1) is not administered to improve dietary intake. Newborns receive it to prevent vitamin K deficiency bleeding, as they have low levels of vitamin K at birth due to limited placental transfer.

Choice B rationale

Phytonadione does not stimulate the immune system. It is a fat-soluble vitamin essential for the synthesis of clotting factors, which prevents bleeding disorders in newborns.

Choice C rationale

Newborns are given phytonadione to prevent hemorrhagic disorders, which can occur due to their immature liver's inability to produce sufficient clotting factors without adequate vitamin K.

Choice D rationale

While phytonadione supports liver function indirectly by aiding clotting factor synthesis, its primary role is to prevent hemorrhagic disease of the newborn, not directly to help an immature liver develop.

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A new parent asks the nurse about an area of swelling on the baby’s head near the posterior fontanel that lies across the suture line. How should the nurse respond?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A diabetic client delivers a full-term large-for-gestational-age (LGA) infant who is jittery. Which action should the nurse take first?

Correct Answer is A

Explanation

The nurse is preparing to administer phytonadione to a newborn. Which statement made by the parents indicates understanding why the nurse is administering this medication?

Correct Answer is C

Explanation

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The nurse knows that hydralazine, while magnesium sulfate will help prevent seizures, will help decrease blood pressure thus?

A new parent asks the nurse about an area of swelling on the baby’s head near the posterior fontanel that lies across the suture line. How should the nurse respond?