A nurse is caring for a newborn delivered by vaginal birth. The newborn's mother asks about the swollen area on her son's head. After palpation to identify that the swelling does not cross the suture line, which of the following is an appropriate response by the nurse?
"Mongolian spots can be found on the skin of many newborns."
"This is erythema toxicum, which is a transient condition."
"A caput succedaneum occurs due to compression of blood vessels."
"This is a cephalhematoma, which can occur spontaneously."
The Correct Answer is D
A. Mongolian spots are flat pigmented areas, typically on the lower back, unrelated to swelling.
B. Erythema toxicum is a benign newborn rash, not swelling.
C. Caput succedaneum involves soft tissue swelling that does cross suture lines.
D. A cephalhematoma is a collection of blood between the periosteum and skull that does not cross the suture line. It often resolves spontaneously within a few weeks.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Heart Rate: 108 bpm = 2 points, Respiratory Effort: Regular rate with a cry = 2 points, Muscle Tone: Some flexion = 1 point, Reflex Irritability: Vigorous cry with stimulation = 2 points, Color: Pink body, blue extremities (acrocyanosis) = 1 point: Total APGAR Score: 8
B. A. Heart Rate: 108 bpm = 2 points, Respiratory Effort: Regular rate with a cry = 2 points, Muscle Tone: Some flexion = 1 point, Reflex Irritability: Vigorous cry with stimulation = 2 points, Color: Pink body, blue extremities (acrocyanosis) = 1 point: Total APGAR Score: 8
C. A. Heart Rate: 108 bpm = 2 points, Respiratory Effort: Regular rate with a cry = 2 points, Muscle Tone: Some flexion = 1 point, Reflex Irritability: Vigorous cry with stimulation = 2 points, Color: Pink body, blue extremities (acrocyanosis) = 1 point: Total APGAR Score: 8
D. A. Heart Rate: 108 bpm = 2 points, Respiratory Effort: Regular rate with a cry = 2 points, Muscle Tone: Some flexion = 1 point, Reflex Irritability: Vigorous cry with stimulation = 2 points, Color: Pink body, blue extremities (acrocyanosis) = 1 point: Total APGAR Score: 8
Correct Answer is B
Explanation
A. Hormone loss doesn’t directly contribute to early weight loss.
B. Breastfed newborns often lose weight in the first few days after birth due to insufficient milk intake from infrequent or short feedings. The nurse should assess feeding patterns and encourage feeding every 2-3 hours.
C. Water supplements are unnecessary and can interfere with breastfeeding.
D. Frequent stools are normal and usually not a significant cause of excessive weight loss.
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