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 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.
Correct Answer is ["A","B","D","E"]
Explanation
A. Blotting the perineal area dry helps prevent moisture retention, reducing the risk of infection.
B. Performing hand hygiene before and after voiding helps prevent the introduction of bacteria into the perineal area.
C. Applying ice packs may help reduce swelling but is not a routine measure for preventing infection.
D. Cleaning the perineal area from front to back helps prevent the introduction of fecal bacteria into the urethra and vagina.
E. Washing the perineal area using a squeeze bottle of warm water after each voiding helps maintain cleanliness and prevent infection.
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