A nurse is caring for a newborn delivered by vaginal birth with 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?

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

Caput succedaneum occurs due to compression of blood vessels.

This is erythema toxicum, which is a transient condition.

This is a cephalohematoma, which can occur spontaneously.

Answer and Explanation

The Correct Answer is B

Choice a reason:
Mongolian spots are a type of pigmented birthmark commonly found in newborns, often appearing as blue or grayish areas on the skin. They are not related to swelling and do not result from vacuum-assisted deliveries. Mongolian spots are usually located on the buttocks or lower back and are not associated with the type of swelling described by the mother.

Choice b reason:
Caput succedaneum is a condition where the newborn's scalp swells due to pressure during delivery. It is characterized by a soft, spongy mass that crosses suture lines and is most apparent on the part of the skull that was first to enter the birth canal. This condition is common in vacuum-assisted deliveries and is the correct explanation for the swelling observed on the newborn's head.

Choice c reason:
Erythema toxicum is a common and benign skin condition in newborns, presenting as red patches or small, fluid-filled bumps. It is not related to the swelling described and does not result from vacuum-assisted deliveries. Erythema toxicum typically resolves on its own and does not cause the type of swelling that crosses suture lines.

Choice d reason:
Cephalohematoma is a collection of blood between a newborn's scalp and the skull bone that results from ruptured blood vessels, which can be a result of birth trauma or pressure. However, it is typically confined to one area and does not cross suture lines. Since the swelling described by the mother crosses the suture lines, cephalohematoma is less likely to be the correct diagnosis.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["0504"]

Explanation

To calculate the estimated date of birth (EDB), also known as the due date, we use Naegele's Rule, which involves adding one year, subtracting three months, and adding seven days to the first day of the last menstrual period (LMP). Using this rule, if the LMP was on July 27, the EDB would be:

- Add one year: July 27, 2024
- Subtract three months: April 27, 2024
- Add seven days: May 4, 2024

Therefore, the EDB in MMDD format is 0504.
Reason:
Naegele's Rule is a standard way of calculating the due date for a pregnancy. The rule estimates the expected date of delivery (EDD) by adding one year, subtracting three months, and adding seven days to the date of a woman's last menstrual period (LMP). This calculation assumes a regular menstrual cycle of 28 days and ovulation occurring on the 14th day of the cycle. The EDB is typically set at 40 weeks from the LMP, which is approximately 280 days. While this method provides an estimate, only about 4% of births occur on the exact due date, and most births occur within a range of two weeks before or after the estimated due date.

It's important to note that the EDB is an estimate and can be influenced by factors such as the length of menstrual cycles, the exact day of ovulation, and the date of conception. Ultrasounds and other prenatal tests can provide additional information to refine the due date estimate as the pregnancy progresses.

A. In the third trimester B. Shortly after giving birth C. During her next attempt to get pregnant D. Immediately

Correct Answer is B

Explanation

Choice A reason:
Immunization for rubella in the third trimester is not recommended because live vaccines are contraindicated during pregnancy due to the theoretical risk to the fetus.

Choice B reason:
The recommended time for rubella immunization is shortly after giving birth. This timing is advised because the vaccine contains a live virus, which could potentially harm the fetus if given during pregnancy. By waiting until after the delivery, there is no risk to the newborn, and the mother can develop immunity before any subsequent pregnancies.

Choice C reason:
While it is important for a woman to have immunity to rubella before getting pregnant, the immunization should not be given during the time she is trying to conceive. Women are advised to avoid pregnancy for at least 28 days after receiving the MMR vaccine, which includes the rubella component, due to the live virus in the vaccine.

Choice D reason:
Immunization for rubella should not be given immediately upon finding out that the client does not have immunity during the first trimester. As mentioned, live vaccines are contraindicated during pregnancy, and the immunization should be postponed until after the birth of the baby.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a newborn delivered by vaginal birth with 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

A nurse in a prenatal clinic is caring for a client who is pregnant and asks the nurse for her estimated date of birth (EDB). The client's last menstrual period began on July 27. What is the client's EDB? (State the date in MMDD format. For example, July 27 is 0727.)

Correct Answer is ["0504"]

Explanation

A nurse is caring for a client during the first trimester of pregnancy. After reviewing the client's blood work, the nurse notices she does not have immunity to rubella. Which of the following times should the nurse understand is recommended for rubella immunization?

Correct Answer is B

Explanation

A nurse is admitting a term newborn following a cesarean birth. The nurse observes that the newborn's skin is slightly yellow. This finding indicates the newborn is experiencing a complication related to which of the following?

A nurse is caring for a newborn 4 hours after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice?

Which of the following is the priority nursing action for a client at 33 weeks of gestation with a diagnosis of placenta previa?

A nurse is instructing a woman who is contemplating pregnancy about nutritional needs. To reduce the risk of giving birth to a newborn who has a neural tube defect, which of the following information should the nurse include in the teaching?

A nurse is caring for a client who is at 40 weeks of gestation and is in labor. The client's ultrasound examination indicates that the fetus is small for gestational age (SGA). Which of the following interventions should be included in the newborn's plan of care?

A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor?

A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data?