A nurse is assessing a newborn following a vacuum-assisted delivery. Which of the following findings should the nurse report to the provider?

Poor sucking.

Blue coloring of the hands and feet.

Soft, edematous area on the scalp.

Facial edema.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

This finding may indicate a neurological problem or an issue with the baby's ability to feed, which can lead to inadequate nutrition and hydration. It's essential for the newborn to establish good feeding patterns early on

Choice B rationale:

Blue coloring of the hands and feet, also known as acrocyanosis, is a common and normal finding in newborns. It results from the immaturity of the peripheral circulation and usually resolves on its own without any intervention.

Choice C rationale:

A soft, edematous area on the scalp, also known as caput succedaneum, is a common finding following vacuum-assisted delivery and typically resolves without intervention.

Choice D rationale:

Facial edema is another common finding in newborns, especially after vacuum-assisted deliveries. It is typically a transient and self-resolving condition that does not require immediate intervention or reporting to the provider.

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Correct Answer is A

Explanation

Choice A rationale:

Rh incompatibility occurs when an Rh-negative client is exposed to Rh-positive fetal blood, typically during a prior pregnancy or delivery. The client’s immune system produces anti-Rh antibodies that cross the placenta in subsequent pregnancies, attacking the Rh-positive red blood cells of the fetus. This hemolysis releases bilirubin, leading to hyperbilirubinemia in the newborn.

Choice B rationale:

Rh incompatibility only occurs when the client is Rh-negative and the fetus is Rh-positive. An Rh-positive client will not form antibodies against an Rh-negative fetus, as their immune system recognizes the Rh factor as normal.

Choice C rationale:

This choice is not related to the mechanism of Rh incompatibility. Receiving a transfusion with Rh-negative blood would not cause the mother's immune system to produce anti-Rh antibodies or lead to Rh incompatibility with her newborn.

Choice D rationale:

This choice describes the ABO blood group system, not the Rh factor. ABO incompatibility can occur when a mother with blood type O (producing anti-A and anti-B antibodies) has a newborn with blood type A, B, or AB, leading to hemolysis of the fetal red blood cells. However, the question specifically mentions Rh incompatibility, which involves the Rh factor, not the ABO system.

A. Nevus flammeus. B. Caput succedaneum. C. Cephalohematoma. D. Erythema toxicum.

Correct Answer is B

Explanation

Choice A reason:

Nevus flammeus, also known as a port-wine stain, is a flat, pink, red, or purple mark on the skin present at birth. It is a congenital vascular malformation and does not involve swelling that crosses suture lines.

Choice B reason:

Caput succedaneum is the correct diagnosis for swelling that crosses suture lines on a newborn's head, typically associated with a prolonged or difficult vaginal delivery, especially with the use of vacuum extraction.

Choice C reason:

Cephalohematoma is a collection of blood under the periosteum of the cranial bones that does not cross suture lines. It appears soon after birth and is usually caused by birth trauma.

Choice D reason:

Erythema toxicum is a common rash in newborns, presenting as red patches with small white or yellow pustules. It does not cause swelling over the head that crosses suture lines.

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A nurse is assessing a newborn following a vacuum-assisted delivery. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has just delivered her first newborn. The nurse anticipates hyperbilirubinemia due to Rh incompatibility. The nurse should understand that hyperbilirubinemia occurs with Rh incompatibility for which of the following reasons?

Correct Answer is A

Explanation

A nurse is assessing a newborn who was born vaginally with vacuum extractor assistance. The nurse notes swelling over the newborn's head that crosses the suture line. The nurse should identify the swelling as which of the following findings?

Correct Answer is B

Explanation

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