A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The newborn’s mother asks about the swollen area on her son’s head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse?

“This is a cephalhematoma, which can occur spontaneously.”

“Caput succedaneum occurs due to compression of blood vessels.”

“This is erythema toxicum, which is a transient condition.”

“Mongolian spots can be found on the skin of many newborns.”

Answer and Explanation

The Correct Answer is B

A.   A cephalhematoma is a collection of blood under the periosteum that does not cross the suture lines and can take weeks to resolve.
B.   Caput succedaneum occurs due to compression of blood vessels during delivery, resulting in edema and bruising of the scalp. It crosses the suture lines and usually resolves within a few days and does not cause any complications.
C. Erythema toxicum is a rash that is unrelated to head swelling.
D.   Mongolian spots are blue-gray patches on the skin, not associated with head swelling.

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Correct Answer is C

Explanation

A. Using mild soap is a suitable practice for newborn skin care.
B. Testing water temperature before bathing is a safety measure to prevent burns.
C. Baby powder is not recommended for newborns as it can cause respiratory issues when inhaled.
D. Using a basin during bathing is a reasonable approach to facilitate safe and controlled bathing.

A. A newborn who is 18 hr post-delivery and has acrocyanosis B. A newborn who is 24-hr post-delivery and has not passed meconium C. A newborn who is 24 hr post-delivery and has persistent tachycardia with a heart rate of 180 bpm D. A newborn who is 24 hr post-delivery and has not voided

Correct Answer is C

Explanation

A. Acrocyanosis is a normal finding in newborns and does not require immediate intervention.
B. Not passing meconium within the first 24 hours is not uncommon and may be normal.
C. Persistent tachycardia in a newborn, especially with a heart rate of 180 bpm, requires immediate intervention as it may indicate a cardiac or other medical issue.
D. Not voiding within the first 24 hours may be normal, but it should be monitored.

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A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The newborn’s mother asks about the swollen area on her son’s head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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