Within three days of birth, a newborn has developed a yellowish tinge that extends from the face to mid-chest is lethargic, and has to be awakened to feed. Which condition does the nurse suspect this infant is manifesting?
Physiologic jaundice
Pathologic jaundice
Breast milk jaundice
The Correct Answer is A
Physiologic jaundice usually appears between the second and fourth day after birth and resolves by the second week. It is caused by the immature liver's inability to process bilirubin efficiently.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Check for blood under the client's buttock. This is because lochia rubra is the normal vaginal discharge that occurs after childbirth, consisting of blood, mucus, and tissue from the placenta and the uterus lining. It is usually heavy for the first three to four days and can pool under the client's buttocks if they are lying down. Checking for blood under the buttock can help assess the amount of bleeding and prevent complications such as infection or hemorrhage.
The other choices are not correct for the following reasons:
A. Increasing the rate of the IV fluids is not necessary because the client's fundus is firm and midline, indicating that the uterus is contracting well and preventing excessive bleeding.
B. Assisting the client to ambulate is not advisable because it can increase the lochia flow and cause fainting or dizziness due to blood loss.
C. Performing fundal massage is not indicated because the fundus is already firm and midline, meaning that the uterus is adequately contracted. Massaging a firm fundus can cause pain and discomfort to the client.
Correct Answer is A
Explanation
This is because cephalhematoma is a collection of blood under the scalp that does not cross the suture line. It is caused by trauma to the head during delivery, such as from vacuum extraction or forceps. It usually appears within a few hours or days after birth and resolves within weeks or months.


Choice B is not correct because nevus flammeus is a type of birthmark that is also known as port-wine stain. It is a flat, red, or purple patch of skin that can appear anywhere on the body, but often on the face. It is caused by abnormal blood vessels in the skin and does not go away over time³.
Choice C is not correct because the molding is the temporary change in the shape of the head due to pressure during delivery. It does not cause swelling or bruising and usually resolves within a few days.
Choice D is not correct because caput succedaneum is a type of swelling that affects the scalp and crosses the suture line. It is caused by fluid accumulation under the scalp due to pressure during delivery. It usually appears at birth and goes away within a few days.
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