A nurse in a provider's office is collecting data from a 6-week-old infant who developed an uncomplicated cephalohematoma at birth. Which of the following locations should the nurse assess to determine if the infant's lesion has absorbed(You will find hot spots to select in the artwork below in the form of arrows. Select only the hot spot that corresponds to your answer.)
A
B
C
None
None
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The Correct Answer is B
A. This area is over the cheek and facial soft tissue. Cephalohematomas do not occur here, as they are confined to the skull bones under the periosteum.
B. This point is positioned over the parietal area of the skull, the typical site for cephalohematoma formation due to birth trauma. Cephalohematoma is a subperiosteal hemorrhage confined to the surface of the skull, most commonly over the parietal bone, and does not cross suture lines. Palpating this area helps determine whether the lesion has resolved or calcified.
C. This region is the lower abdominal or pelvic area, which is not relevant for assessing cranial birth trauma like cephalohematoma.
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Correct Answer is C
Explanation
A. Absence of Babinski reflex: The Babinski reflex (a fanning of the toes when the sole of the foot is stroked) is normal in infants and should be present until around 12 months of age. Its absence at 6 weeks would be atypical.
B. Absence of Moro reflex: The Moro reflex (a startle response) is typically present in newborns and may begin to disappear by 3-6 months of age. Its absence at 6 weeks would be concerning and could indicate neurological issues.
C. Closure of the posterior fontanel: The posterior fontanel typically closes by 6-8 weeks of age. This is a normal finding for a 6-week-old infant.
D. Closure of the anterior fontanel: The anterior fontanel typically closes between 12 and 18 months of age, not by 6 weeks. Therefore, closure of the anterior fontanel at 6 weeks would be unusual.
Correct Answer is C
Explanation
A. Skin condition: The fine rash noted on the chest and abdomen is not itchy, which is a common finding in infectious mononucleosis. It is not a primary concern unless it worsens or develops other characteristics, but it is not the most urgent issue to report.
B. Temperature: The client's temperature of 38.2°C (100.8°F) is slightly elevated, which is typical in infectious mononucleosis. It is within the expected range for the condition, and the prescribed acetaminophen should help manage the fever.
C. Pain level: The client reports significant pain in the left upper quadrant (rated 8 on a scale of 0 to 10) that worsens with palpation. This could indicate splenic involvement, which is a serious complication of mononucleosis, as the spleen can become enlarged and rupture.
D. Intake: The client is drinking at least 8 cups of water per day and eating about 60% of meals, which is an adequate fluid intake for the current state. Although not perfect, the intake is not a primary concern at this time compared to the pain level.
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