A nurse is assessing a newborn the day after delivery. The nurse notes a raised, bruised area on the left side of the scalp that does not cross the suture line. How should the nurse document this finding?
Molding
Caput succedaneum
Pilonidal dimple
Cephalhematoma
The Correct Answer is D
A. Molding refers to the shaping of the fetal head during labor and delivery to facilitate passage through the birth canal. It typically resolves within a few days and does not involve bruising.
B. Caput succedaneum is localized swelling or edema of the scalp that crosses suture lines and typically resolves within a few days. It is not associated with bruising.
C. Pilonidal dimple refers to a small pit or depression in the skin, typically at the base of the spine, and is not related to the finding described.
D. Cephalhematoma is a collection of blood between the skull bone and its periosteum. It is
confined by suture lines and may take weeks to resolve. It does not cross suture lines and may be associated with bruising due to birth trauma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Feeding the baby every 2 hours helps to ensure frequent emptying of the breasts, which can help alleviate engorgement by reducing milk stasis and promoting milk production regulation.
Applying cold compresses before feeding may temporarily reduce discomfort but does not address the underlying cause of engorgement or promote milk removal.
Drinking herbal tea is not proven to effectively reduce breast engorgement, and it is important for the client to focus on frequent breastfeeding or pumping to alleviate engorgement.
Allowing the baby to drain one breast at each feeding may lead to uneven milk production and exacerbate engorgement. It is important for the client to offer both breasts at each feeding to ensure adequate milk removal from both breasts.
Correct Answer is C
Explanation
A. Monitoring weight is important for assessing growth but may not be the priority for a
newborn who is small for gestational age (SGA) as it doesn't address immediate physiological needs.
B. Monitoring axillary temperature is important for detecting signs of infection or hypothermia, but it's not the priority for a newborn who is small for gestational age (SGA).
C. Monitoring blood glucose levels is the priority for a newborn who is small for gestational age (SGA) because they are at risk for hypoglycemia due to inadequate glycogen stores.
D. Monitoring intake and output is important for overall assessment but is not the priority intervention for a newborn who is small for gestational age (SGA).
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