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.
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Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Assisting the client to a sitz bath is not the priority action in this situation. The client has soaked two perineal pads in the past 30 minutes, indicating excessive bleeding, which requires immediate attention.
Choice B rationale:
Assessing the client's uterine tone is essential to determine if the uterus is contracting appropriately. Uterine atony, where the uterus fails to contract after childbirth, is a common cause of postpartum hemorrhage. Assessing the tone helps identify this issue and allows for timely interventions.
Choice C rationale:
Encouraging the client to breastfeed may have benefits such as promoting uterine contractions through oxytocin release. However, the priority in this scenario is addressing the potential postpartum hemorrhage.
Choice D rationale:
Applying an ice pack to the client's perineum may provide comfort, but it does not address the concerning symptom of excessive bleeding and potential postpartum hemorrhage.
Correct Answer is C
Explanation
Choice C rationale:
Hypotension is a finding that indicates the client is experiencing decreased cardiac output. Excessive vaginal bleeding can lead to hypovolemia, reducing the volume of blood pumped by the heart and resulting in decreased cardiac output. The body responds to hypovolemia and decreased cardiac output by trying to maintain blood pressure, which leads to hypotension.
Choice A rationale:
Bradycardia is not a finding indicating decreased cardiac output in this scenario. While bradycardia (abnormally slow heart rate) can be associated with decreased cardiac output in certain situations, it is not the primary finding in a postpartum client experiencing excessive vaginal bleeding.
Choice B rationale:
A flushed face is not an indicator of decreased cardiac output. A flushed face may result from various factors such as fever or emotional stress, but it is not directly related to cardiac output.
Choice D rationale:
Polyuria (excessive urination) is not an indicator of decreased cardiac output. Polyuria may occur due to factors like diuresis or increased fluid intake but is not directly related to cardiac output in the context of excessive vaginal bleeding.
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