A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The newborn’s mother asks about the swollen area on her son’s head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse?
“This is a cephalhematoma, which can occur spontaneously.”
“Caput succedaneum occurs due to compression of blood vessels.”
“This is erythema toxicum, which is a transient condition.”
“Mongolian spots can be found on the skin of many newborns.”
The Correct Answer is B
A. A cephalhematoma is a collection of blood under the periosteum that does not cross the suture lines and can take weeks to resolve.
B. Caput succedaneum occurs due to compression of blood vessels during delivery, resulting in edema and bruising of the scalp. It crosses the suture lines and usually resolves within a few days and does not cause any complications.
C. Erythema toxicum is a rash that is unrelated to head swelling.
D. Mongolian spots are blue-gray patches on the skin, not associated with head swelling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Placing an identification bracelet is important but not the immediate priority after ensuring a patent airway.
B. Drying the skin is a priority to prevent heat loss and promote thermoregulation in the newborn.
C. Administering vitamin K is important but can be done after drying the skin.
D. Administering eye prophylaxis is important but can be done after drying the skin.
Correct Answer is A
Explanation
A. Breast milk typically comes in 3 to 5 days postpartum.
B. This timeline is too early for the onset of mature breast milk.
C. This timeline is too late for the onset of mature breast milk.
D. This timeline is too late for the onset of mature breast milk.
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