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?
Nevus flammeus.
Caput succedaneum.
Cephalohematoma.
Erythema toxicum.
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Requesting a prescription for PRN aspirin is incorrect because aspirin is an antiplatelet agent and should not be combined with heparin without specific medical advice due to the increased risk of bleeding.
Choice B reason:
Massaging the injection site is not recommended as it can cause trauma to the tissue and increase the risk of bleeding, which is especially concerning in a patient with deep-vein thrombosis.
Choice C reason:
Instructing the client that they cannot breastfeed while receiving heparin is incorrect. Heparin does not pass into breast milk in significant amounts and is considered safe for use while breastfeeding.
Choice D reason:
Administer the injection in the client's abdomen. Heparin is typically administered subcutaneously in the abdomen to ensure proper absorption and minimize discomfort. Because it is an area with large amounts of subcutaneous fat
Correct Answer is B
Explanation
Choice A rationale:
Hyporeactivity is not typically associated with neonatal abstinence syndrome (NAS) NAS is characterized by increased irritability and signs of withdrawal, which are opposite to a hypo- reactive state.
Choice B rationale:
An excessive high-pitched cry is a hallmark sign of neonatal abstinence syndrome. Babies exposed to drugs like methadone during pregnancy can experience withdrawal symptoms, including a distinct high-pitched cry.
Choice C rationale:
Acrocyanosis, a bluish discoloration of the extremities, is a common finding in newborns and is not specific to NAS. It is caused by immature peripheral circulation and usually resolves on its own.
Choice D rationale:
A respiratory rate of 50/min is within the normal range for a newborn and is not a sign of neonatal abstinence syndrome. NAS symptoms are related to drug withdrawal and not respiratory issues.
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