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. Applying petroleum jelly is not recommended with the Plastibell technique as it may interfere with the ring falling off.
B. The client should also keep the diaper loose in the front to prevent pressure or irritation on the penis.
C. The ring to fall off by itself within 5 to 10 days. Do not try to remove it yourself or pull on it.
D. Washing with warm water and mild soap is generally good hygiene but may not be necessary for circumcision care.
Correct Answer is A
Explanation
A. The presence of lochia rubra with small clots in the immediate postpartum period is expected. The firm and midline fundus indicates appropriate uterine contraction. Continued monitoring is appropriate.
B. Encouraging the client to empty her bladder is a valid intervention, but it is not the priority in this situation.
C. Increasing the frequency of fundal massage is unnecessary, as the fundus is already firm.
D. Notifying the provider is not necessary based on the described findings, as they are within the expected range.
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