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
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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.
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Naxlex Comprehensive Predictor Exams
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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.
Correct Answer is C
Explanation
A. Temperature: A temperature of 38.6°C (101.5°F) is elevated, but fever is a common symptom of bacterial pneumonia. It is important to monitor, but it is not the most critical finding in this case.
B. Skin condition: Hives and flushing could be signs of an allergic reaction to medication, but this is not immediately life-threatening. The nurse should report it, but the priority in this case is the oxygen saturation, which reflects the patient's respiratory status.
C. Oxygen saturation: Oxygen saturation of 93% is below the typical threshold of 95-100% and indicates mild hypoxemia. In a patient with bacterial pneumonia, low oxygen saturation signify worsening respiratory function. This requires immediate attention and reporting.
D. Lung sounds: Coarse crackles in the right lower lobe are expected in pneumonia due to lung consolidation. While it is important to monitor lung sounds, the priority is addressing the oxygen saturation level, which is directly related to the patient's ability to breathe effectively.
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