A nurse is caring for a newborn who was delivered by vacuum extraction and has swelling on his head that crosses the suture line. The newborn's mother asks about the swelling on her newborn's head. Which of the following responses should the nurse make?
"This is a Mongolian spot, which is found on many newborns.".
"This is a caput succedaneum, which is a collection of fluid from pressure of the vacuum extractor.".
"This is erythema toxicum, which is a transient allergic reaction that causes edema in the skin.".
"This is a cephalhematoma, which will resolve on its own in 3 to 5 days.".
The Correct Answer is B
"This is a caput succedaneum, which is a collection of fluid from the pressure of the vacuum extractor.”.
Choice A rationale:
A Mongolian spot is a benign, flat, bluish-gray pigmented area often found on the sacral or gluteal area of some newborns with darker skin tones. It is not related to the swelling on the newborn's head caused by vacuum extraction.
Choice B rationale:
A caput succedaneum is a localized swelling on the baby's scalp that occurs due to pressure from the vacuum extractor during delivery. It is typically soft and may cross the suture lines. This explanation accurately describes the swelling the baby has on his head.
Choice C rationale:
Erythema toxicum is a common rash that appears as small red bumps with white or yellow centers. It is a benign and self-resolving condition that does not cause swelling on the head or involve the suture lines.
Choice D rationale:
A cephalhematoma is a collection of blood between the skull and the periosteum that does not cross the suture lines. It is caused by trauma during birth and may take weeks to months to resolve. This does not match the description of the swelling caused by vacuum extraction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
This is the priority finding because a bilirubin level of 18 mg/dL in a 4-hour-old newborn is significantly elevated. High bilirubin levels in newborns can lead to jaundice, which can be harmful if not promptly addressed. Hyperbilirubinemia in newborns requires close monitoring and, in some cases, treatment with phototherapy.
Choice B rationale:
A hemoglobin level of 22 g/dL is within the normal range for a newborn and is not a priority concern at this time.
Choice C rationale:
A blood glucose level of 50 mg/dL is within the normal range for a newborn. While monitoring blood glucose levels is essential, it is not the priority in this situation.
Choice D rationale:
A platelet count of 200,000/mm³ is within the normal range for a newborn and does not require immediate action.
Correct Answer is B
Explanation
"This is a caput succedaneum, which is a collection of fluid from the pressure of the vacuum extractor.”.
Choice A rationale:
A Mongolian spot is a benign, flat, bluish-gray pigmented area often found on the sacral or gluteal area of some newborns with darker skin tones. It is not related to the swelling on the newborn's head caused by vacuum extraction.
Choice B rationale:
A caput succedaneum is a localized swelling on the baby's scalp that occurs due to pressure from the vacuum extractor during delivery. It is typically soft and may cross the suture lines. This explanation accurately describes the swelling the baby has on his head.
Choice C rationale:
Erythema toxicum is a common rash that appears as small red bumps with white or yellow centers. It is a benign and self-resolving condition that does not cause swelling on the head or involve the suture lines.
Choice D rationale:
A cephalhematoma is a collection of blood between the skull and the periosteum that does not cross the suture lines. It is caused by trauma during birth and may take weeks to months to resolve. This does not match the description of the swelling caused by vacuum extraction.
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