A nurse is caring for a newborn delivered by vaginal birth with 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?
Mongolian spots can be found on the skin of many newborns.
Caput succedaneum occurs due to compression of blood vessels.
This is erythema toxicum, which is a transient condition.
This is a cephalohematoma, which can occur spontaneously.
The Correct Answer is B
Choice a reason:
Mongolian spots are a type of pigmented birthmark commonly found in newborns, often appearing as blue or grayish areas on the skin. They are not related to swelling and do not result from vacuum-assisted deliveries. Mongolian spots are usually located on the buttocks or lower back and are not associated with the type of swelling described by the mother.
Choice b reason:
Caput succedaneum is a condition where the newborn's scalp swells due to pressure during delivery. It is characterized by a soft, spongy mass that crosses suture lines and is most apparent on the part of the skull that was first to enter the birth canal. This condition is common in vacuum-assisted deliveries and is the correct explanation for the swelling observed on the newborn's head.
Choice c reason:
Erythema toxicum is a common and benign skin condition in newborns, presenting as red patches or small, fluid-filled bumps. It is not related to the swelling described and does not result from vacuum-assisted deliveries. Erythema toxicum typically resolves on its own and does not cause the type of swelling that crosses suture lines.
Choice d reason:
Cephalohematoma is a collection of blood between a newborn's scalp and the skull bone that results from ruptured blood vessels, which can be a result of birth trauma or pressure. However, it is typically confined to one area and does not cross suture lines. Since the swelling described by the mother crosses the suture lines, cephalohematoma is less likely to be the correct diagnosis.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice a) reason: Pelvic pain is a common symptom of endometritis. The pain is typically located in the lower abdomen and may be associated with uterine tenderness upon physical examination. This symptom, especially when combined with other signs such as fever and foul-smelling lochia, strongly suggests the need for further evaluation for endometritis.
Choice b) reason: Hematuria, or blood in the urine, is not a typical symptom of endometritis. While it could be a sign of other postpartum complications, such as urinary tract infections or bladder injury during childbirth, it does not directly indicate endometritis.
Choice c) reason: A localized area of breast tenderness is more indicative of a breast infection, such as mastitis, especially if associated with breastfeeding. It is not a symptom of endometritis, which affects the uterus and not the breasts.
Choice d) reason: While foul-smelling lochia can be a sign of endometritis, the key is the presence of a foul odor. A moderate amount of dark red lochia alone, without a foul odor, is a normal finding in the immediate postpartum period. It's the transition from rubra (red) to serosa (pink/brown) to alba (yellow/white) that is expected as the uterus heals.
Correct Answer is B
Explanation
Choice A reason:
Covering the cord with a sterile, moist saline dressing can help to maintain the cord's viability by preventing drying and possible infection. However, this action does not address the immediate concern of relieving pressure on the cord to restore fetal circulation.
Choice B reason:
Placing the client in the knee-chest position is the most immediate and critical action to take. This position helps to relieve pressure on the prolapsed cord, which is vital to prevent compression of the cord and maintain blood flow to the fetus. It is a recommended emergency intervention for umbilical cord prolapse.
Choice C reason:
Inserting a gloved hand into the vagina to relieve pressure on the cord is a measure that may be taken by a healthcare provider in the event of a cord prolapse. However, it is not the first action to be performed. The initial step is to change the mother's position to relieve pressure on the cord.
Choice D reason:
Preparing the client for an immediate birth is necessary because umbilical cord prolapse is an obstetric emergency that requires prompt delivery, often by cesarean section, to prevent fetal hypoxia. However, the very first action is to relieve pressure on the cord to restore fetal oxygenation while preparations for delivery are made.
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