A new parent asks the nurse about an area of swelling on the baby’s head near the posterior fontanel that lies across the suture line. How should the nurse respond?

“That is called caput succedaneum. It will have to be drained.”.

“That is called a cephalhematoma. It can cause jaundice as it is absorbed.”.

“That is called a cephalhematoma. It will cause no problems.”.

“That is called caput succedaneum. It will absorb and cause no problems.”.

A couple who plan to use in-vitro fertilization with donated sperm.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Caput succedaneum is a benign swelling of the soft tissues of the scalp that crosses suture lines and does not require drainage.

Choice B rationale

Cephalhematoma is a collection of blood between the skull and periosteum that does not cross suture lines; it may contribute to jaundice as it is reabsorbed by the body.

Choice C rationale

While cephalhematoma usually resolves without intervention, it is important to monitor for potential complications, including jaundice, due to the breakdown of red blood cells.

Choice D rationale

Caput succedaneum typically resolves on its own without intervention, as the fluid is gradually absorbed by the body over time.

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Correct Answer is B

Explanation

Choice A rationale

Documenting the finding without further action is inappropriate when faced with an abnormal FHR pattern. Immediate intervention is crucial to prevent potential fetal hypoxia or distress, necessitating a prompt response.

Choice B rationale

Notifying the healthcare provider is essential when encountering abnormal FHR patterns. Timely communication allows for appropriate interventions to be implemented, reducing the risk of adverse fetal outcomes and ensuring patient safety.

Choice C rationale

Scheduling an ultrasound is not the immediate priority when an abnormal FHR pattern is detected. Immediate clinical evaluation and interventions are necessary to address potential fetal distress or hypoxia.

Choice D rationale

Obtaining a hematocrit level is unrelated to the immediate management of abnormal FHR patterns. The priority is to address the fetal well-being and ensure adequate oxygenation through timely clinical interventions.

A. Notify the nursery about the client’s response. B. Restart oxytocin infusion rate per protocol. C. Stop oxygen per cannula. D. Check for clonus in both feet.

Correct Answer is B

Explanation

Choice A rationale

Notifying the nursery about the client’s response is not an immediate intervention. It is more important to manage uterine contractions and fetal oxygenation before informing other departments about the client's condition.

Choice B rationale

Restarting the oxytocin infusion rate per protocol is necessary to resume labor induction. Oxytocin increases uterine contractions, promoting cervical dilation and progression of labor. Continuous monitoring is required to adjust the dosage.

Choice C rationale

Stopping oxygen per cannula is not recommended if fetal distress is present. Oxygen supplementation ensures adequate fetal oxygenation during uterine contractions, reducing the risk of hypoxia and related complications.

Choice D rationale

Checking for clonus in both feet is not relevant to the current scenario. Clonus is a neurological sign indicating hyperreflexia, often unrelated to labor management. The focus should be on managing uterine contractions and fetal well-being.

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A new parent asks the nurse about an area of swelling on the baby’s head near the posterior fontanel that lies across the suture line. How should the nurse respond?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which action should the nurse take?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

The nurse reports the current assessment findings to the healthcare provider (HCP). Based on the assessment findings, the priority diagnosis suspected is preeclampsia. This diagnosis places the client at risk of which complications?

The nurse is preparing to administer phytonadione to a newborn. Which statement made by the parents indicates understanding why the nurse is administering this medication?

A nurse is caring for a 24-year-old pregnant woman in the prenatal clinic. She is gravida 2, para 1 (G2P1), and her mother has a history of type 2 diabetes mellitus. Exhibits: Exhibits Which is likely causing this client's increased blood glucose at 28 weeks? Select all that apply.

The nurse is reviewing the prescriptions to determine priorities. Which prescriptions take priority?

Which action is most important for the nurse to implement?

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After two miscarriages, a client is instructed to increase her daily intake of foods that includes folic acid. The client does not like green leafy vegetables and states she is allergic to soy. Which food should the nurse suggest that the client eat to obtain folic acid?