How it Works
Try Naxlex NCLEX-RN (Free-Trial)

Infants in whom cephalohematomas develop are at increased risk for:

A.

Caput succedaneum.

B.

Jaundice.

C.

Infection.

D.

Erythema toxicum.

Answer and Explanation

The Correct Answer is B

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.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is D

Explanation

Choice A rationale

Applying heat to the breasts in mastitis can increase blood flow and potentially worsen inflammation. While heat can be comforting for engorgement, in mastitis, it may exacerbate the inflammatory response and should be used cautiously or avoided in the acute phase. The primary goal is to remove milk and reduce inflammation.

Choice B rationale

Removing the nursing bra might provide some temporary comfort if the bra is too tight and constricting milk flow. However, it does not address the underlying infection or inflammation of mastitis. Supportive nursing bras are generally recommended to provide support without restricting milk ducts.

Choice C rationale

Given the early indications of mastitis, such as a hard, warm area in the breast, moderate lochia rubra (which is normal for postpartum day 3), and a fundus appropriately descended, additional interventions are indeed indicated to prevent the progression of the infection and promote healing. Ignoring these signs could lead to a more severe infection.

Choice D rationale

Continued breastfeeding is crucial for managing mastitis. Frequent emptying of the breasts helps to remove the stagnant milk, which can contribute to the infection. Breast milk has antimicrobial properties that can aid in resolving the infection. Encouraging the client to breastfeed frequently on the affected side, starting with that side, promotes drainage and healing.

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"}}

Explanation

Rationales for Each Condition

Molar Pregnancy

  1. Abdominal Pain: In a molar pregnancy, the uterus enlarges disproportionately due to abnormal trophoblastic growth. This excessive expansion can cause discomfort or mild cramping.
  2. Blood Pressure: Molar pregnancies can be associated with gestational trophoblastic disease, which may lead to preeclampsia-like symptoms. However, this client’s blood pressure is currently within normal limits (120/78 mm Hg), so severe hypertension has not yet developed.
  3. Ultrasound Findings: The presence of grape-like vesicles within the uterus and the absence of a fetal heartbeat are hallmark findings of a molar pregnancy, indicating abnormal placental tissue proliferation.
  4. Perineal Pad Findings: The passage of small clear vesicles is a characteristic feature of a molar pregnancy, distinguishing it from other causes of vaginal bleeding in pregnancy.

Ectopic Pregnancy

  1. Abdominal Pain: Ectopic pregnancies often cause sharp lower abdominal pain due to tubal rupture or irritation. However, in this case, the client’s pain is mild and less suggestive of tubal rupture.
  2. Blood Pressure: If an ectopic pregnancy ruptures, hypotension due to internal bleeding would be expected. Since the client’s blood pressure is normal, this finding does not support an ectopic pregnancy.
  3. Ultrasound Findings: The absence of a fetal heartbeat and vesicular structures inside the uterus make ectopic pregnancy unlikely, as ectopic pregnancies typically occur in the fallopian tube.
  4. Perineal Pad Findings: Ectopic pregnancies rarely cause the passage of vesicular tissue, further suggesting that this is not an ectopic pregnancy.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register