A nurse is collecting data from a newborn and notes a swollen area on the head that does not cross the suture line. The nurse should document this finding as which of the following?
Cephalhematoma.
Nevus flammeus.
Caput succedaneum.
Molding.
The Correct Answer is A
Choice A rationale:
Cephalhematoma is the correct answer because it presents as a swelling on the newborn's head confined to one cranial bone and does not cross suture lines. It usually resolves on its own within a few weeks to months but can increase the risk of jaundice due to the breakdown of red blood cells in the hematoma.
Choice B rationale:
Nevus flammeus, also known as a port-wine stain, is a type of vascular birthmark. It presents as a flat, pink, or red mark on the skin and does not involve swelling of the head. This choice is unrelated to the findings described in the question and is therefore incorrect.
Choice C rationale:
Caput succedaneum refers to a diffuse, soft tissue swelling of the scalp that does cross suture lines. It is caused by pressure on the head during delivery, leading to edema and bruising. It typically resolves within a few days after birth.
Choice D rationale:
Molding refers to the shaping of the fetal head during childbirth as it passes through the birth canal. It may cause temporary elongation or molding of the head, but it does not present as a localized swollen area. This choice is not applicable to the findings mentioned in the question and is thus incorrect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Reporting the client's weight to the provider is not a priority in this situation. While weight is important, the immediate concern is the newborn's respiratory distress and the acidosis indicated by the blood gases.
Choice B rationale:
Selecting diagnostic studies for the primary health care is not the nurse's role. The primary health care provider will determine which diagnostic studies are needed based on the newborn's clinical presentation and assessment findings.
Choice C rationale:
Checking brachial pulses for the client's respiratory status is the appropriate action. In a newborn with respiratory distress, assessing peripheral perfusion, including brachial pulses, is crucial to monitor the circulation and oxygenation of tissues.
Correct Answer is D
Explanation
A. This is not a primary consideration before bathing a newborn. The timing of the last feeding is more relevant to assessing the risk of hypoglycemia rather than determining readiness for a bath.
B. This temperature is slightly below the recommended range for newborns (36.5°C to 37.5°C). Bathing should be delayed until the newborn's temperature is stable.
C. While care of the umbilical cord is important, it does not determine the timing of the first bath. The cord can be kept dry even if the baby is bathed.
D. Ensuring that the newborn has maintained a stable body temperature for at least 2 hours is crucial before giving the first bath. Bathing can cause a drop in body temperature, so it's essential that the newborn's thermoregulation is stable to avoid hypothermia.
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