A nurse is examining a newborn’s head and observes a diffuse edema over the scalp that crosses the suture lines.
The nurse recognizes this as a caput succedaneum.
What should the nurse do next?
Notify the physician immediately.
Document the finding and monitor for resolution.
Apply ice packs to reduce swelling.
Perform a neurological assessment.
The Correct Answer is B
Document the finding and monitor for resolution. Caput succedaneum is a harmless condition that causes swelling of the scalp due to pressure during delivery. It does not indicate any damage to the brain or the skull and usually resolves on its own within a few days.
Therefore, the nurse should document the finding and monitor for resolution.
Choice A is wrong because there is no need to notify the physician immediately. Caput succedaneum is not a medical emergency and does not require any intervention.
Choice C is wrong because applying ice packs to reduce swelling is not recommended. Ice packs can cause skin irritation, infection, or hypothermia in newborns.
Choice D is wrong because performing a neurological assessment is not necessary. Caput succedaneum does not affect the brain or the nervous system and does not cause any neurological symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The anterior fontanel is normal and the posterior fontanel is normal.
According to, the average size of the anterior fontanel is2.1 cm, and the median time of closure is13.8 months.The posterior fontanel generally closes2 to 3 monthsafter birth.
Therefore, a 6-month-old infant with an anterior fontanel of 4 cm and a closed posterior fontanel is within the normal range.
Choice A is wrong because the posterior fontanel is not delayed in closing.It usually closes by 3 months of age.
Choice C is wrong because the anterior fontanel is not enlarged.It can range from 0.6 cm to 3.6 cm with a mean of 2.1 cm.
Choice D is wrong because both the anterior and posterior fontanels are normal, not enlarged or delayed in closing.
Normal ranges for head circumference of a 6-month-old infant are39.59 to 44.34 cmfor girlsand40.89 to 45.34 cmfor boys, according to the CDC.
Correct Answer is A
Explanation
Birth trauma.A cephalohematoma is a collection of blood under the scalp of a newborn that forms a bulge.It is caused by rupture of blood vessels crossing the periosteum due to pressure or trauma on the fetal head during birth.This pressure or trauma may result from a prolonged second stage of labor, instrumental delivery, particularly forceps delivery, ventouse application, or the baby’s head squeezing through the birth canal.
Choice B is wrong because infection is not a cause of cephalohematoma, but a potential complication that may occur in some cases.
Choice C is wrong because dehydration is not a cause of cephalohematoma, but a possible consequence of anemia, which may result from blood loss.
Choice D is wrong because hemorrhage is not a cause of cephalohematoma, but a synonym for bleeding, which is what happens when the blood vessels rupture.
Normal ranges for newborn cephalohematoma are not applicable, as it is an abnormal condition that varies in size and severity.However, most cephalohematomas resolve on their own without intervention within weeks or months.
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