A nurse is providing care for a newborn diagnosed with hydrocephalus. Which of the following symptoms should the nurse anticipate?
A forehead that slopes backward.
Dilated veins on the scalp.
Overlapping suture lines.
Hypertension.
The Correct Answer is B
Hydrocephalus is a condition where there is an accumulation of cerebrospinal fluid (CSF) in the brain, causing increased pressure inside the skull. This can cause dilated veins on the scalp in a newborn.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale: Documenting the findings and continuing to monitor the client is appropriate because the nurse has already observed that the fundus is midline and firm, which indicates good uterine tone. The presence of lochia rubra and small clots is expected in the immediate postpartum period.
Choice B rationale: Encouraging the client to empty her bladder can help maintain uterine tone, but in this scenario, the fundus is already firm and midline, so this is not the priority action.
Choice C rationale: Notifying the client's provider is unnecessary at this time because the findings are within normal postpartum expectations and the uterus is firm.
Choice D rationale: Increasing the frequency of fundal massage is not needed because the uterus is already firm and midline, indicating that it is contracting properly.
Correct Answer is D
Explanation
Choice A rationale
Chadwick’s sign is a bluish discoloration of the cervix, vagina, and labia resulting from increased blood flow. This sign is commonly seen in early pregnancy, but it does not indicate the presence of blood in the peritoneum.
Choice B rationale
Chvostek’s sign is a clinical sign of existing nerve hyperexcitability seen in hypocalcemia. It refers to an abnormal reaction to the stimulation of the facial nerve. This sign is not related to a ruptured ectopic pregnancy.
Choice C rationale
Goodell’s sign is a significant softening of the vaginal portion of the cervix from increased vascularization. This vascular softening is seen in early pregnancy. It does not indicate the presence of blood in the peritoneum.
Choice D rationale
Cullen’s sign is the appearance of bruising in the skin around the umbilicus. It occurs when there is blood in the peritoneum, or intra-abdominal bleeding. In the case of a suspected ruptured ectopic pregnancy, Cullen’s sign would indicate the presence of blood in the peritoneum.
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