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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Feed the infant at least 1 ounce of formula: Feeding may help if the baby is hungry, but it is not the first action in managing symptoms of NAS.
B. Collect a sterile urine specimen: This is an important step for diagnosing NAS but is not the immediate action to calm the infant.
C. Swaddle the infant with hands near its mouth: These symptoms are consistent with neonatal abstinence syndrome (NAS). Comfort measures such as swaddling and non-nutritive sucking are prioritized to soothe the infant.
D. Move the infant into a brightly lit area: A quiet, dim environment is better for soothing an overstimulated baby, so this action would be counterproductive.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
Meconium aspiration syndrome (MAS) occurs when a newborn inhales meconium-stained amniotic fluid during or after delivery, leading to respiratory distress. This newborn has several findings consistent with MAS:
Dark brown-greenish amniotic fluid during labor indicates meconium-stained fluid.
Fine crackles throughout lung fields and expiratory grunting suggest impaired gas exchange and possible airway obstruction.
Rapid and shallow respirations (80/min) and the presence of green-stained vernix and fingernails further support this diagnosis.
Jaundice, hypoglycemia, and cold stress are also potential complications in newborns but are not the most immediate threats based on this newborn's clinical presentation.
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