Try Naxlex NCLEX-RN (Free-Trial)

  1. 16. A nurse is caring for a newborn who is 4 hr old.

    Nurses' Notes

    Large ecchymotic caput succedaneum noted on occiput with molding of the skull. Anterior fontanel level and soft.
    Newborn's respirations are shallow and irregular.

    Newborn's skin color is consistent with their genetic background. Acrocyanosis noted. The newborn is active and moves all extremities except for left arm. Left arm remains at side during Moro reflex. Bilateral gluteal folds equal. Base of spine closed.
    Breastfed vigorously for 30 min.

    Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

    The newborn most likely has as evidenced by Condition a clavicle fracture neonatal abstinence syndrome (NAS) developmental dysplasia of the hip (DDH) a subgaleal hemorrhage a congenital cardiac defect
Answer and Explanation

The Correct Answer is ["Moro reflex color of extremities head assessment maternal urine toxicology screen gluteal folds"]

Subgaleal hemorrhage is a rare but potentially serious condition in newborns characterized by bleeding beneath the scalp's galea aponeurotica, a fibrous tissue layer between the scalp and the skull.
 
 
 


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

The newborn should be placed in prone position to prevent pressure to the lesion which may lead to damage to the contents of the sac. It should be covered with a sterile, wet gauze to maintain the integrity of the sac.

Correct Answer is ["B","D","F"]

Explanation

Correct Choices for Indicating Understanding:

  • "I should make sure that my baby feeds 8 to 12 times per day."
  • "My baby's stools should turn to a yellow color within the next day or two."
  • "I should expect my breasts to become harder, warmer, and more tender when my milk comes in."

Rationale

  • "Because of my baby's weight loss, I need to supplement with formula after breastfeeding."

    • This statement does not necessarily indicate an understanding of discharge teaching, as supplementation should only be done based on medical advice and not solely based on perceived weight loss.

  • "I should make sure that my baby feeds 8 to 12 times per day."

    • This statement indicates an understanding of discharge teaching, as frequent feeding is important for newborns to ensure adequate nutrition and hydration, and to promote milk production in breastfeeding mothers.

  • "I should cover my sore nipples with plastic-lined breast pads after every feeding."

    • This statement does not indicate proper understanding, as plastic-lined breast pads can retain moisture and increase the risk of infection. Instead, breathable pads or natural remedies are often recommended.

  • "My baby's stools should turn to a yellow color within the next day or two."

    • This statement indicates an understanding of normal neonatal stool changes, as breastfed babies' stools typically transition to a yellow color within a few days of birth.

  • "I can increase my milk supply by drinking more water."

    • While staying hydrated is important, this statement alone is insufficient for indicating a comprehensive understanding of increasing milk supply. Effective breastfeeding practices and frequent nursing are more directly impactful.

  • "I should expect my breasts to become harder, warmer, and more tender when my milk comes in."

    • This statement indicates an understanding of the common experience of breast engorgement when milk comes in, which is a normal part of the breastfeeding process.

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