A newborn is being assessed for risk of hyperbilirubinemia. The infant has both caput succedaneum and a cephalohematoma. The nurse understands that phototherapy is more likely to be required in which condition, and why?

Caput succedaneum can lead to severe bruising and therefore often requires phototherapy.

Neither condition increases bilirubin levels so phototherapy is not needed for either.

Phototherapy is more likely needed with caput succedaneum because it increases blood cell breakdown under the scalp.

Cephalohematoma increases the risk of hyperbilirubinemia due to the breakdown of trapped red blood cells, which may require phototherapy.

Answer and Explanation

The Correct Answer is D

A. Caput succedaneum is incorrect because this condition is a diffuse swelling of the scalp that crosses suture lines and is caused by pressure during delivery. It usually resolves on its own within a few days and does not significantly increase bilirubin levels or require phototherapy.

B. Neither condition increases bilirubin levels is incorrect because cephalohematoma can significantly elevate bilirubin due to red blood cell breakdown within the localized hematoma. While caput succedaneum has minimal impact, cephalohematoma can contribute to hyperbilirubinemia.

C. Phototherapy is more likely needed with caput succedaneum is incorrect because the swelling in caput succedaneum does not contain trapped blood and therefore does not cause significant hemolysis or increase bilirubin levels.

D. Cephalohematoma increases the risk of hyperbilirubinemia is correct because cephalohematoma is a collection of blood between the skull and periosteum that is confined by suture lines. The trapped red blood cells break down over time, releasing bilirubin into the bloodstream. This delayed bilirubin rise can become significant and often requires phototherapy to prevent complications such as kernicterus.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Pull the baby out forcefully by the head with forceps is incorrect because forceful traction can cause severe injury to the baby, including brachial plexus injury, clavicle fracture, or intracranial hemorrhage. This is not recommended for shoulder dystocia.

B. Apply gentle upward traction on the baby's head is incorrect because while gentle traction is part of standard delivery, upward traction alone is usually insufficient to resolve shoulder dystocia and may risk injury if used improperly.

C. Wait for the mother to push the shoulders out naturally is incorrect because shoulder dystocia is an obstetric emergency. Delaying intervention can lead to hypoxia, birth asphyxia, or fetal injury, so immediate maneuvers are required.

D. Place the mother in McRoberts maneuver position and apply suprapubic pressure is correct. The McRoberts maneuver involves flexing the mother’s hips tightly toward her abdomen, which flattens the sacral promontory and increases the pelvic diameter. Simultaneously, suprapubic pressure helps dislodge the impacted anterior shoulder. This is the first-line, evidence-based intervention for shoulder dystocia and reduces the risk of fetal and maternal complications.

A. Increasing the child's intake of high-fat foods to address malnutrition B. Encouraging increased fluid intake to help with hydration and thin mucus C. Administering inhaled corticosteroids to reduce airway inflammation D. Initiating chest physiotherapy (CPT) to promote airway clearance and reduce mucus build-up

Correct Answer is D

Explanation

A. Increasing the child’s intake of high-fat foods is incorrect as the primary concern in this scenario is acute respiratory compromise, not malnutrition. While high-calorie, high-fat diets are important for CF management to address nutritional deficits, this intervention does not immediately improve airway clearance or reduce respiratory symptoms.

B. Encouraging increased fluid intake is partially correct because hydration helps thin mucus, making it easier to clear. However, hydration alone is insufficient for managing acute airway obstruction, especially when the child has decreased breath sounds and increased respiratory secretions.

C. Administering inhaled corticosteroids is incorrect as these reduce airway inflammation over time but are not the first-line intervention for acute mucus obstruction or compromised ventilation. They are adjunctive therapy rather than the priority in acute management.

D. Initiating chest physiotherapy (CPT) is correct because CF causes thick, sticky mucus that obstructs the airways, leading to infection and decreased oxygenation. CPT, including percussion, vibration, and postural drainage, helps mobilize mucus, improve ventilation, prevent atelectasis, and reduce the risk of further respiratory complications. This is considered the priority nursing intervention for acute respiratory exacerbations in CF.

View Question and Answer

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

A newborn is being assessed for risk of hyperbilirubinemia. The infant has both caput succedaneum and a cephalohematoma. The nurse understands that phototherapy is more likely to be required in which condition, and why?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the delivery of a newborn when the head is delivered, but the shoulders become stuck behind the maternal pubic bone. Which of the following is the nurse's priority action?

Correct Answer is D

Explanation

Correct Answer is D

Explanation

A nurse is assessing a 4-year-old child who presents with symptoms suggestive of epiglottitis. Which of the following clinical manifestations would be most consistent with this condition?

A nurse in the emergency department is assessing a 4-month-old infant who has suspected pertussis. Which of the following findings should the nurse identify as consistent with this diagnosis? (Select all that apply.)

A 5-year-old child is recovering after undergoing surgery for a brain tumor. The nurse is reviewing the child's postoperative care plan. The child is alert, but the nurse notices that the child is vomiting and complaining of a headache. The nurse's priority action should be:

A 4-year-old child is diagnosed with nephrotic syndrome. Which of the following findings would the nurse expect to observe?

A 7-year-old child is brought to the clinic due to fatigue, slowed growth, and constipation. On examination, the child has dry skin, a puffy face, and a hoarse voice. Which of the following conditions should the nurse suspect?

A 3-week-old infant is brought to the emergency department with a history of forceful, projectile vomiting after feedings and signs of weight loss. On assessment, the nurse palpates a small, olive-shaped mass in the upper abdomen. Which condition does this clinical picture most likely indicate?

A 25-year-old woman is considering starting oral contraceptives. Which of the following conditions are contraindications for her to use combination oral contraceptives? (Select all that apply.)