A neonate, who is one day old, develops a cephalhematoma.
Which common complication should the nurse assess this neonate for?
Poor appetite.
Jaundice.
Hypoglycemia.
Brain damage.
The Correct Answer is B
Choice A rationale
Poor appetite can be a symptom of many neonatal conditions, but it's not the most common complication specifically associated with cephalhematoma.
Choice B rationale
Cephalhematomas are caused by the rupture of blood vessels between the skull and periosteum, resulting in a blood collection. The breakdown of red blood cells in this trapped blood can lead to the release of bilirubin, increasing an infant's risk for hyperbilirubinemia and jaundice.
Choice C rationale
Hypoglycemia is a potential concern in neonates but is not directly related to cephalhematoma.
Choice D rationale
While brain damage is a serious potential complication in cases of severe skull trauma, it's not typically associated with cephalhematoma alone. Cephalhematomas usually resolve on their own without long-term consequences.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
While swaddling the infant in a warm blanket can help maintain body temperature, it does not address the underlying issue causing the symptoms.
Choice B rationale
Documenting the findings in the record is important, but it is not the immediate action that should be taken. The newborn’s symptoms suggest a possible health issue that needs immediate attention.
Choice C rationale
Placing a pulse oximeter on the infant’s heel can provide information about the newborn’s oxygen saturation, but it does not address the immediate concern of the symptoms presented.
Choice D rationale
Obtaining a heel stick blood glucose level is the correct action. The symptoms presented by the newborn such as jitteriness, hypotonicity, and a weak cry can be signs of hypoglycemia, a condition that can occur in newborns.
Correct Answer is A
Explanation
Choice A rationale
A postpartum client experiencing severe pain and a sensation of pressure in her perineum, along with the formation of a perineal hematoma, is in a potentially serious situation. The nurse should first assess the client’s heart rate and blood pressure. This is because a perineal hematoma can lead to significant blood loss, which could cause changes in these vital signs.
Choice B rationale
While monitoring urinary output and IV fluid intake can be important in the overall assessment of a postpartum client, these are not the most immediate concerns when a perineal hematoma is forming.
Choice C rationale
Checking hemoglobin and hematocrit levels can provide information about the client’s blood volume and potential blood loss. However, this would likely be done after initial vital signs are assessed and stabilized.
Choice D rationale
Assessing abdominal contour and bowel sounds would not be the most immediate concern in this situation. These assessments would be more relevant if there were concerns about postpartum complications related to the client’s gastrointestinal system.
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