A nurse is assessing a newborn the day after delivery. The nurse notes a raised, bruised area on the left side of the scalp that does not cross the suture line. How should the nurse document this finding?

Molding

Caput succedaneum

Pilonidal dimple

Cephalhematoma

Answer and Explanation

The Correct Answer is D

A.   Molding refers to the shaping of the fetal head during labor and delivery to facilitate passage through the birth canal. It typically resolves within a few days and does not involve bruising.
B.   Caput succedaneum is localized swelling or edema of the scalp that crosses suture lines and typically resolves within a few days. It is not associated with bruising.
C.   Pilonidal dimple refers to a small pit or depression in the skin, typically at the base of the spine, and is not related to the finding described.
D.   Cephalhematoma is a collection of blood between the skull bone and its periosteum. It is

confined by suture lines and may take weeks to resolve. It does not cross suture lines and may be associated with bruising due to birth trauma.

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Correct Answer is B

Explanation

A. Petechiae and bleeding around the IV access site are not typically associated with preeclampsia.
B. Disseminated intravascular coagulation (DIC) is a potential complication of abruptio placentae, characterized by widespread activation of the clotting cascade followed by consumption of clotting factors, leading to bleeding and microvascular thrombosis.

C. Puerperal infection is a risk following childbirth but is not specifically associated with petechiae and bleeding around the IV access site.
D. Anaphylactoid syndrome of pregnancy is a rare complication characterized by sudden hypotension, bronchospasm, and vascular collapse, which is not typically associated with petechiae and bleeding around the IV access site.

A. A newborn who is 24-hr post-delivery and has not passed meconium B. A newborn who is 12 hr post-delivery and has a temperature of 37.5° C (99.5° F) C. A newborn who is 18 hr post-delivery and has acrocyanosis D. A newborn who is 24 hr post-delivery and has not voided

Correct Answer is D

Explanation

A. Not passing meconium within 24 hours may indicate meconium ileus or another bowel obstruction, but it's not an immediate concern.

B. A temperature of 37.5°C (99.5°F) is within the normal range for a newborn and does not require immediate intervention.
C. Acrocyanosis, blueness of the extremities, is a common finding in newborns and does not require immediate intervention.
D. A newborn who is 24 hours post-delivery and has not voided requires immediate intervention as it may indicate a urinary tract obstruction or another issue that needs prompt assessment and management.

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A nurse is assessing a newborn the day after delivery. The nurse notes a raised, bruised area on the left side of the scalp that does not cross the suture line. How should the nurse document this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on the obstetric unit is caring for a client who experienced abruptio placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse should recognize that this client is at risk for which of the following complications?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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