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.

Answer and Explanation

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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Correct Answer is D

Explanation

Choice A reason:
Urinary frequency typically begins early in pregnancy due to hormonal changes and increased blood volume leading to more fluid being processed by the kidneys and ending up in the bladder. While it often improves in the second trimester as the uterus rises into the abdominal cavity, poor bladder tone is not typically cited as a reason for its continuation.

Choice B reason:
While urinary frequency can be seen as a minor inconvenience, it should not be ignored. It is a normal physiological change during pregnancy. However, if it is accompanied by pain, burning, or any other symptoms, it could indicate a urinary tract infection, which requires medical attention.

Choice C reason:
There is some predictability to urinary frequency in pregnancy. It often starts in the first trimester, improves in the second, and may return in the third trimester as the growing baby and uterus exert pressure on the bladder.

Choice D reason:
This choice is accurate. Urinary frequency is common in the first trimester due to hormonal changes and the growing uterus pressing on the bladder. It often returns in the third trimester when the baby "drops" and the head presses on the bladder. This is a normal part of pregnancy and usually does not indicate any complications.

A. Soft, edematous area on the scalp B. Blue coloring of the hands and feet C. Facial edema D. Poor sucking

Correct Answer is D

Explanation

Choice A reason:
A soft, edematous area on the scalp, often referred to as a cephalohematoma, is a common finding after vacuum-assisted deliveries. This is due to the suction applied during delivery and usually resolves without intervention. However, it should be monitored for any signs of increased swelling or jaundice as it can sometimes lead to hyperbilirubinemia.

Choice B reason:
The blue coloring of the hands and feet, known as acrocyanosis, is a normal finding in the first few days of life. It occurs due to the immature circulation in the newborn and typically resolves as the baby's circulation adapts to life outside the womb.

Choice C reason:
Facial edema can be present in newborns following a vacuum-assisted delivery due to the pressure applied during the procedure. It is usually transient and resolves within a few days. However, persistent or severe edema may warrant further evaluation.

Choice D reason:
Poor sucking is a significant finding that should be reported to the provider. Effective sucking is crucial for adequate nutrition and hydration in the newborn. Poor sucking can be a sign of neurological compromise or other issues that require immediate attention to ensure the baby can feed properly and thrive.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A nurse is assessing a newborn following a vacuum-assisted delivery. Which of the following findings should the nurse report to the provider?

Correct Answer is D

Explanation

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