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 B

Explanation

A. Applying petroleum jelly is not recommended with the Plastibell technique as it may interfere with the ring falling off.
B. The client should also keep the diaper loose in the front to prevent pressure or irritation on the penis.
C. The ring to fall off by itself within 5 to 10 days. Do not try to remove it yourself or pull on it.
D. Washing with warm water and mild soap is generally good hygiene but may not be necessary for circumcision care.

A. Temperature 37.4° C, heart rate 88 bpm, respirations 36 breaths per minute, and blood pressure 126/68 mm Hg B. Temperature 36.8° C, heart rate 60 bpm, respirations 18 breaths per minute, and blood pressure 140/90 mm Hg C. Temperature 38° C, heart rate 80 bpm, respirations 16 breaths per minute, and blood pressure 110/80 mm Hg D. Temperature 37.9° C, heart rate 120 beats per minute (bpm), respirations 20 breaths per minute, and blood pressure 90/50 mm Hg

Correct Answer is D

Explanation

A. While the heart rate and respiratory rate are elevated, the blood pressure and temperature are within an acceptable range.
B. The heart rate and respiratory rate are within normal limits, and the blood pressure is elevated but not as concerning as other options.
C. The temperature and blood pressure are within normal limits, and while the heart rate is slightly elevated, it is not as concerning as other options.
D. The elevated heart rate, low blood pressure, and elevated temperature may indicate hypovolemic shock, which is of greatest concern given the history of significant estimated blood loss.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates understanding of circumcision care?

Correct Answer is B

Explanation

A woman gave birth to a 7-pound, 6-ounce infant girl 1 hour ago. The birth was vaginal and the estimated blood loss (EBL) was 1500 ml. When evaluating the woman's vital signs, which finding would be of greatest concern to the nurse?

Correct Answer is D

Explanation

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