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.”
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The priority is to assess the client's uterine fundus to determine if it is well-contracted. Excessive bleeding could be indicative of uterine atony, and prompt assessment is crucial for intervention.
B. Assisting the client on a bedpan to urinate is a secondary intervention. While a distended bladder can contribute to uterine atony, assessing the fundus comes first to determine the cause.
C. Increasing fluid intake is important for postpartum recovery, but it is not the immediate priority in this situation.
D. Preparing to administer oxytocic medication may be necessary if uterine atony is identified during the fundal assessment. However, assessing the fundus comes first to guide appropriate interventions.
Correct Answer is D
Explanation
A. Wearing a loose-fitting bra may provide comfort but does not address the underlying issue of engorgement.
B. Expressing small amounts of milk may stimulate further milk production and is not recommended in cases of bottle-feeding.
C. Running warm water on the breasts may increase blood flow and exacerbate swelling.
D. Cold compresses or ice are more appropriate for relieving discomfort and reducing swelling.
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