A nurse in a provider's office is collecting data from a 6-week-old infant who developed an uncomplicated cephalohematoma at birth. Which of the following locations should the nurse assess to determine if the infant's lesion has absorbed(You will find hot spots to select in the artwork below in the form of arrows. Select only the hot spot that corresponds to your answer.)
A
B
C
None
None
None
The Correct Answer is B
A. This area is over the cheek and facial soft tissue. Cephalohematomas do not occur here, as they are confined to the skull bones under the periosteum.
B. This point is positioned over the parietal area of the skull, the typical site for cephalohematoma formation due to birth trauma. Cephalohematoma is a subperiosteal hemorrhage confined to the surface of the skull, most commonly over the parietal bone, and does not cross suture lines. Palpating this area helps determine whether the lesion has resolved or calcified.
C. This region is the lower abdominal or pelvic area, which is not relevant for assessing cranial birth trauma like cephalohematoma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
A. Ensure the scale is balanced to "0" before weighing the infant: It is important to calibrate the scale to "0" before weighing the infant to ensure an accurate measurement. This step helps to avoid any errors in weight assessment.
B. Place a stadiometer on the top of the infant's head to measure their length: A stadiometer is typically used for measuring height in older children and adults, but for infants, a length board (not a stadiometer) should be used.
C. Cover the scale with a clean sheet of paper: This is essential for hygiene and to provide a clean, warm surface for the infant, especially when they are undressed for weighing.
D. Obtain the infant's weight with their diaper on: To obtain an accurate weight, the infant should be weighed without the diaper. A diaper adds weight that could affect the accuracy of the measurement.
E. Measure the infant's length from the crown of the head to the heels of the feet: For accurate length measurements in infants, the measurement should be taken from the crown of the head to the heels of the feet while the infant is lying flat on a length board.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}
Explanation
Rationale:
- Insert a peripheral IV catheter: A peripheral IV catheter is essential for administering fluids and medications, which is critical for this adolescent, especially with the concern for bacterial meningitis.
- Place the adolescent on a cooling blanket: The adolescent has a high fever (39°C), which needs to be managed promptly to prevent further complications. A cooling blanket helps reduce the fever and manage the patient’s temperature.
- Administer IV acyclovir: Acyclovir is an antiviral medication typically used to treat viral infections such as herpes simplex virus or varicella-zoster virus, not bacterial meningitis. Given the CSF findings and suspected bacterial meningitis, acyclovir is not appropriate. Antibiotics like cefotaxime are indicated instead.
- Place on seizure precautions: Given the adolescent's symptoms (e.g., headache, photophobia, lethargy), the risk of seizures is elevated, especially if meningitis is suspected. Seizure precautions are important to prevent injury during a potential seizure.
- Keep adolescent flat in bed for 24 hr post lumbar puncture: After a lumbar puncture, keeping the adolescent flat in bed for 24 hours helps prevent post-lumbar puncture headaches and minimizes the risk of cerebrospinal fluid leaks or complications.
- Administer IV cefotaxime: IV cefotaxime is an appropriate antibiotic for treating bacterial meningitis. Given the abnormal CSF results (low glucose, high protein, elevated WBC), the adolescent is at high risk for bacterial meningitis, and IV cefotaxime is expected to be part of the treatment plan.
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