A nurse is caring for an infant who has a cephalohematoma on the left side of his skull.

Which of the following interventions should the nurse implement?

Monitor for signs of jaundice

Apply pressure dressing over the area

Administer antibiotics as prescribed

Elevate the head of the bed.

Answer and Explanation

The Correct Answer is A

Monitor for signs of jaundice. A cephalohematoma is a collection of blood under the scalp that occurs due to trauma or pressure during delivery. It may increase the risk of jaundice in the newborn due to the breakdown of red blood cells and the release of bilirubin. Jaundice is a condition that causes yellowing of the skin and eyes due to high levels of bilirubin in the blood. Monitoring for signs of jaundice is important to prevent complications such as brain damage or kernicterus.

Apply pressure dressing over the area. This is wrong because applying pressure may increase the bleeding and cause more damage to the scalp and skull. A cephalohematoma does not require any treatment and usually resolves on its own within weeks or months.

Administer antibiotics as prescribed. This is wrong because antibiotics are not indicated for a cephalohematoma unless there is evidence of infection. Infection is a rare complication that may lead to osteomyelitis or meningitis. Antibiotics should be used only if prescribed by a doctor based on clinical signs and laboratory tests.

Elevate the head of the bed. This is wrong because elevating the head of the bed may not have any effect on a cephalohematoma. It may also cause discomfort or compromise the airway of the newborn. The position of the baby should be adjusted according to their comfort and safety.

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Correct Answer is B

Explanation

Bulging fontanelles.Bulging fontanelles can be a sign of increased intracranial pressure or intracranial and extracranial tumors.This is a potential problem for the newborn’s brain and health and should be evaluated by imaging studies.

Choice A is wrong because sunken fontanelles are usually a sign of dehydration, which is not a problem with the fontanelles themselves, but with the fluid balance of the newborn.

Choice C is wrong because a diamond-shaped anterior fontanelle is normal for a newborn.The anterior fontanelle is the largest and most important for clinical evaluation.It has an average size of 2.1 cm and a median time of closure of 13.8 months.

Choice D is wrong because a triangular posterior fontanelle is also normal for a newborn.The posterior fontanelle is smaller than the anterior one and normally closes by 8 weeks.

A. Skin thickness and presence of lanugo B. Flexion in different positions C. Creases on the bottom of feet D. Scrotum development.

Correct Answer is B

Explanation

Flexion in different positions.The New Ballard Scale is a scale that estimates the gestational age of a newborn infant based on physical and neuromuscular characteristics.Flexion in different positions is one of the six neuromuscular signs that are assessed using the scale.The other neuromuscular signs are square window, arm recoil, popliteal angle, scarf sign, and heel to ear.

The other statements are wrong because:

Skin thickness and presence of lanugo are physical signs, not neuromuscular signs.They are also assessed using the New Ballard Scale, along with plantar surface, breast, eye/ear, and genitals.

Creases on the bottom of feet are part of the plantar surface assessment, which is a physical sign, not a neuromuscular sign.

Scrotum development is part of the genital assessment, which is a physical sign, not a neuromuscular sign.

The New Ballard Scale can be used up to 4 days after birth, but usually within the first 24 hours.The scale is accurate only within plus or minus 2 weeks.The total score determines the gestational maturity in weeks.

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A nurse is caring for an infant who has a cephalohematoma on the left side of his skull. Which of the following interventions should the nurse implement?

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A nurse is caring for an infant who has a cephalohematoma on the left side of his skull.

Which of the following interventions should the nurse implement?