During the admission of a newborn, the nurse identifies a localized swelling that does not cross the suture line on the posterior area of the parietal bone. Which action should the nurse implement?
Apply direct pressure to the caput succedaneum.
Submit a request for a STAT Computerized Tomography (CT) scan of the head.
Notify the pediatrician of the cephalhematoma.
Assess neurological vital signs every 4 hours.
The Correct Answer is C
Choice A rationale
Caput succedaneum is a benign, self-limiting condition and does not require direct pressure. It resolves on its own within a few days after birth. Applying pressure may cause unnecessary discomfort to the newborn.
Choice B rationale
A STAT CT scan of the head is not necessary for diagnosing cephalhematoma, which is a localized collection of blood between the skull and periosteum. CT scans are typically reserved for more severe neurological concerns.
Choice C rationale
A cephalhematoma, characterized by swelling that does not cross suture lines, requires notification of the pediatrician. It may increase the risk of hyperbilirubinemia and needs monitoring for potential complications.
Choice D rationale
While assessing neurological vital signs every 4 hours is important for overall newborn care, it does not address the specific condition of cephalhematoma. The primary concern is monitoring for complications such as jaundice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Low back pain and pelvic cramping after amniocentesis can indicate complications such as premature labor or infection, which requires immediate medical attention.
Choice B rationale
Headache and blurred vision are less indicative of complications from amniocentesis; these symptoms are more commonly associated with conditions like preeclampsia.
Choice C rationale
Increased fetal movement is not typically a complication of amniocentesis and does not directly relate to immediate maternal or fetal health concerns.
Choice D rationale
Epigastric pain is not a specific complication of amniocentesis; it is more commonly associated with gastrointestinal issues or, in severe cases, preeclampsia.
Correct Answer is C
Explanation
Choice A rationale
Confirming Rh and Coombs status is essential for Rho(D) immunoglobulin administration, but it is not the immediate priority during acute bleeding as it does not directly address maternal or fetal distress.
Choice B rationale
Performing a sterile vaginal examination could potentially worsen bleeding if placental abruption or previa is present, making it a less safe option. The immediate concern is to assess fetal and maternal well-being.
Choice C rationale
Assessing the fetal heart rate and contraction pattern provides critical information on the fetus's condition and helps determine whether there is fetal distress, which is vital in deciding the urgency of interventions.
Choice D rationale
Determining fetal position using Leopold maneuvers is not a priority during acute bleeding episodes since it does not provide immediate information on fetal well-being or the cause of the bleeding.
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