An African American woman noticed some bruises on her newborn girl's buttocks.
She asks the nurse who spanked her daughter.
The nurse explains that these marks are called:

Choice A rationale

Caput succedaneum is swelling of the soft tissues of the newborn's scalp, often caused by pressure during vaginal delivery. It is a separate condition from cephalohematoma, which involves bleeding between the periosteum and the skull bone. Therefore, cephalohematoma does not increase the risk for caput succedaneum.

Choice B rationale

Jaundice, or hyperbilirubinemia, is a common condition in newborns due to the breakdown of fetal red blood cells and the immature liver's inability to efficiently process bilirubin. Cephalohematomas involve the rupture of blood vessels, leading to an increased breakdown of red blood cells. This releases more bilirubin into the bloodstream, thus elevating the risk of jaundice in infants with cephalohematomas. Normal total bilirubin levels in newborns range from 1 to 12 mg/dL, varying with age in days.

Choice C rationale

Infection is a risk associated with any break in the skin or invasive procedure, but a cephalohematoma itself is a collection of blood beneath the periosteum and does not inherently create an open wound or direct pathway for infection. While infection of a cephalohematoma is possible, it is not a primary increased risk associated with its development.

Choice D rationale

Erythema toxicum is a common, benign skin rash seen in newborns, characterized by small, yellow-white papules or pustules surrounded by red skin. Its etiology is unknown but it is thought to be an inflammatory reaction of the hair follicles. It is not related to the presence or development of a cephalohematoma.

Choice A rationale

Hourly monitoring of deep tendon reflexes is crucial in clients receiving magnesium sulfate for severe preeclampsia. Magnesium sulfate acts as a central nervous system depressant, and diminished or absent deep tendon reflexes (normal range: 2+ to 4+) can indicate magnesium toxicity, necessitating immediate intervention to prevent serious complications like respiratory depression.

Choice B rationale

A urinary output of less than 30 mL per hour signals potential renal hypoperfusion, which can be exacerbated by severe preeclampsia and magnesium sulfate administration. Reduced kidney function can lead to the accumulation of magnesium, increasing the risk of toxicity. Prompt notification of the physician allows for timely adjustments in the treatment plan.

Choice C rationale

Calcium gluconate is the antidote for magnesium sulfate overdose. Having it readily available is essential in case the client exhibits signs of magnesium toxicity, such as respiratory depression, severe hypotension, or loss of reflexes. Prompt administration of calcium gluconate can reverse the effects of magnesium and prevent life-threatening complications.

Choice E rationale

Hourly monitoring of intake and output is vital to assess fluid balance and renal function in pregnant clients with severe preeclampsia receiving magnesium sulfate. Accurate measurement helps in detecting oliguria, a sign of worsening preeclampsia or magnesium toxicity, allowing for timely interventions to maintain adequate hydration and prevent complications.

Choice F rationale

Severe preeclampsia significantly impacts both renal and cardiac function due to widespread vasoconstriction and endothelial dysfunction. Close monitoring of these systems through laboratory tests (e.g., serum creatinine, BUN, electrolytes, ECG) and clinical assessments is essential to detect and manage potential complications such as acute kidney injury, heart failure, and arrhythmias.