The nurse is conducting a newborn assessment and identifies a collection of blood beneath the newborn’s scalp that does not cross the suture lines.
How should the nurse document this finding?

Occiput posterior.

Caput succedaneum.

Cephalohematoma.

Sinciput.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Occiput posterior is a term used to describe the position of the baby’s head during labor and delivery, not a condition related to a collection of blood beneath the newborn’s scalp.
Choice B rationale
Caput succedaneum refers to a localized swelling of the scalp of a newborn caused by pressure on the head during delivery. It is not limited by suture lines and usually resolves within a few days.
Choice C rationale
Cephalohematoma is a collection of blood under the scalp of a newborn baby, specifically between the scalp and the skull, and does not cross the suture lines. It is usually caused by minor trauma to the head during childbirth.
Choice D rationale
Sinciput is a term used to describe the part of the fetal head that is presented first in childbirth, not a condition related to a collection of blood beneath the newborn’s scalp.

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Correct Answer is B

Explanation

The correct answer is choiceB. Expressions of excitement.

Choice A rationale:

Eagerness to learn newborn care skills is more characteristic of the “taking-hold” phase, which follows the “taking-in” phase.During the taking-hold phase, the mother becomes more independent and starts to take an active role in caring for her newborn.

Choice B rationale:

Expressions of excitement are typical during the “taking-in” phase. This phase occurs in the first 1-2 days postpartum, where the mother is primarily focused on herself and her birth experience.She may be excited and talkative about the birth process.

Choice C rationale:

Focus on the family unit and its members is more aligned with the “letting-go” phase, which is the final phase of maternal postpartum adjustment.In this phase, the mother starts to integrate the newborn into the family and adjusts to her new role.

Choice D rationale:

Lack of appetite can occur during the “taking-in” phase due to exhaustion and the physical demands of labor, but it is not a defining characteristic of this phase.

A. A newborn who is 24 hours post-delivery and has not voided B. A newborn who is 18 hours post-delivery and has acrocyanosis C. A newborn who is 12 hours post-delivery and has a temperature of 37.5°C (99.5°F) D. A newborn who is 24 hours post-delivery and has not passed meconium

Correct Answer is D

Explanation

Choice A rationale
A newborn typically begins to void within 24 hours after birth, so not voiding within this time frame is not immediately concerning.
Choice B rationale

Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns, especially within the first few hours after birth. It is a normal finding and does not require immediate intervention.
Choice C rationale
A temperature of 37.5°C (99.5°F) is within the normal range for a newborn. Therefore, this does not require immediate attention.
Choice D rationale
Newborns typically pass meconium, the first stool, within 24 to 48 hours after birth. If a newborn has not passed meconium within 24 hours, it could indicate a problem such as meconium ileus, a complication of cystic fibrosis, or other conditions that might obstruct the bowel. This situation requires immediate attention and intervention.

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The nurse is conducting a newborn assessment and identifies a collection of blood beneath the newborn’s scalp that does not cross the suture lines. How should the nurse document this finding?

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The nurse is conducting a newborn assessment and identifies a collection of blood beneath the newborn’s scalp that does not cross the suture lines.
How should the nurse document this finding?