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A nurse is caring for a newborn delivered by vaginal birth after 3 hours of pushing.
The newborn’s mother asks about the swollen area on her son’s head.
After palpation and identification that the swelling does cross the suture line, which of the following is an appropriate response by the nurse?

“This is erythema toxicum, which is a transient condition.”.

“A caput succedaneum occurs due to prolonged pressure of the head against the cervix.”.

“Mongolian spots can be found on the skin of many newborns.”.

“This is a cephalhematoma, which can occur spontaneously.”. .

Answer and Explanation

The Correct Answer is B

Choice A rationale

Erythema toxicum is a common, benign rash in newborns but does not cause swelling that crosses suture lines.

Choice B rationale

A caput succedaneum is swelling of the scalp that crosses suture lines and is caused by prolonged pressure on the head during delivery.

Choice C rationale

Mongolian spots are benign, flat, congenital birthmarks with wavy borders and irregular shapes, typically found on the lower back and buttocks, not the head.

Choice D rationale

A cephalhematoma is a collection of blood between the skull bone and its periosteum that does not cross suture lines. .

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Correct Answer is D

Explanation

Choice A rationale

Stretching arms out and then back in is a common reflex in newborns known as the Moro reflex. It is not a sign of feeding readiness but rather a response to a sudden loss of support or a loud noise.

Choice B rationale

Turning the head toward a parent’s voice is a sign of auditory recognition and bonding, not necessarily feeding readiness. It indicates the infant’s ability to recognize familiar sounds.

Choice C rationale

Grasping a parent’s finger when placed in the infant’s palm is a primitive reflex known as the palmar grasp reflex. It is not related to feeding readiness but is a normal reflexive action in newborns.

Choice D rationale

Bringing their hand to their mouth is a sign of feeding readiness. This action indicates that the infant is hungry and ready to feed. It is an early cue that the baby is ready to eat.

A. Tickle the outer edge of the sole of the newborn’s foot moving up toward the toes. B. Turn the newborn’s head quickly to one side. C. Hold the newborn vertically allowing one foot to touch the table surface. D. Clap near the crib and make a loud noise.

Correct Answer is A

Explanation

Choice A rationale

The Babinski reflex is elicited by stroking the outer edge of the sole of the newborn’s foot, moving up toward the toes. This causes the big toe to move upward and the other toes to fan out.

Choice B rationale

Turning the newborn’s head quickly to one side is used to elicit the tonic neck reflex, not the Babinski reflex.

Choice C rationale

Holding the newborn vertically and allowing one foot to touch the table surface is used to elicit the stepping reflex, not the Babinski reflex.

Choice D rationale

Clapping near the crib and making a loud noise is used to elicit the startle (Moro) reflex, not the Babinski reflex.

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A nurse is caring for a newborn delivered by vaginal birth after 3 hours of pushing.The newborn’s mother asks about the swollen area on her son’s head.After palpation and identification that the swelling does cross the suture line, which of the following is an appropriate response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is A

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