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:
The pattern of contractions can be a sign of true labor when they are regular, frequent, and increase in intensity and duration over time. In true labor, contractions do not subside with rest or hydration and become progressively more organized. However, contractions alone can be misleading, as Braxton Hicks contractions may also present a pattern but do not lead to cervical changes.

Choice b reason:
The station of the presenting part refers to the position of the baby's head (or presenting part) in relation to the ischial spines of the mother's pelvis. While the station can indicate how far labor has progressed, it is not a definitive sign of true labor. The station changes as labor progresses, but it can also be affected by other factors such as the baby's position.

Choice c reason:
Rupture of the membranes, commonly known as water breaking, can occur before or during labor. While it is a sign that labor may be imminent, it does not confirm true labor. Some women may experience premature rupture of membranes without contractions or cervical changes.

Choice d reason:
Changes in the cervix, including effacement (thinning) and dilation (opening), are the most reliable signs of true labor. Effacement is measured in percentages, and dilation is measured in centimeters. The cervix must be 100% effaced and dilated to 10 centimeters for childbirth to occur. These changes are a direct result of true labor contractions and indicate that the body is preparing for delivery.

A. Suction excess mucus with a bulb syringe. B. Initiate early feeding. C. Prepare for an exchange blood transfusion. D. Begin phototherapy.

Correct Answer is B

Explanation

Choice A reason:
Suctioning excess mucus with a bulb syringe is a standard procedure to clear the airways of a newborn and facilitate breathing. While it is an important aspect of initial newborn care, it does not directly prevent jaundice. Jaundice is caused by high levels of bilirubin in the blood, and suctioning mucus does not influence bilirubin levels.

Choice B reason:
Initiating early feeding, whether breastfeeding or formula feeding, is recommended to prevent jaundice. Early feeding helps stimulate bowel movements, which aids in the excretion of bilirubin through the stool. Breastfed babies should be fed eight to twelve times a day during their first week of life, and formula-fed babies should receive one to two ounces (30 to 60 milliliters) of formula every two to three hours during their first week. This frequent feeding schedule helps ensure that bilirubin does not build up to high levels in the newborn's system.

Choice C reason:
Preparing for an exchange blood transfusion is a treatment measure for severe jaundice, not a preventive action. This procedure is only considered when bilirubin levels are dangerously high and could potentially cause brain damage. It is not a standard preventive measure for jaundice in newborns.

Choice D reason:
Beginning phototherapy is a treatment method for newborns who have already developed jaundice, not a preventive measure. Phototherapy uses light to break down bilirubin in the skin, making it easier for the baby's body to eliminate it. While effective in treating jaundice, it is not used as a preventive action.
Question 65

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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

A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor?

Correct Answer is D

Explanation

A nurse is caring for a newborn 4 hours after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice?

Correct Answer is B

Explanation

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