A nurse is caring for a newborn who was delivered by vacuum extraction and has swelling on his head that crosses the suture line. The newborn's mother asks about the swelling on her newborn's head. Which of the following responses should the nurse make?
"This is a Mongolian spot, which is found on many newborns.".
"This is a caput succedaneum, which is a collection of fluid from pressure of the vacuum extractor.".
"This is erythema toxicum, which is a transient allergic reaction that causes edema in the skin.".
"This is a cephalhematoma, which will resolve on its own in 3 to 5 days.".
The Correct Answer is B
"This is a caput succedaneum, which is a collection of fluid from the pressure of the vacuum extractor.”.
Choice A rationale:
A Mongolian spot is a benign, flat, bluish-gray pigmented area often found on the sacral or gluteal area of some newborns with darker skin tones. It is not related to the swelling on the newborn's head caused by vacuum extraction.
Choice B rationale:
A caput succedaneum is a localized swelling on the baby's scalp that occurs due to pressure from the vacuum extractor during delivery. It is typically soft and may cross the suture lines. This explanation accurately describes the swelling the baby has on his head.
Choice C rationale:
Erythema toxicum is a common rash that appears as small red bumps with white or yellow centers. It is a benign and self-resolving condition that does not cause swelling on the head or involve the suture lines.
Choice D rationale:
A cephalhematoma is a collection of blood between the skull and the periosteum that does not cross the suture lines. It is caused by trauma during birth and may take weeks to months to resolve. This does not match the description of the swelling caused by vacuum extraction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
One ounce is equivalent to 29.57 ml (30 mls when rounded off to the nearest whole number). This conversion is essential in pediatric care, especially when administering medications to infants, as doses are often prescribed in milliliters.
Choice B rationale:
One ounce is equivalent to 29.57 ml (30 mls when rounded off to the nearest whole number). This conversion is essential in pediatric care, especially when administering medications to infants, as doses are often prescribed in milliliters.
Choice C rationale:
One ounce is equivalent to 29.57 ml (30 mls when rounded off to the nearest whole number). This conversion is essential in pediatric care, especially when administering medications to infants, as doses are often prescribed in milliliters.
Choice D rationale:
One ounce is equivalent to 29.57 ml (30 mls when rounded off to the nearest whole number). This conversion is essential in pediatric care, especially when administering medications to infants, as doses are often prescribed in milliliters.
Correct Answer is ["A","D"]
Explanation
Choice A rationale:
Respiratory distress is a priority assessment finding that indicates a newborn may be experiencing cold stress. Cold stress can cause the baby's body to burn brown fat to generate heat, leading to increased oxygen demand and respiratory distress as a compensatory mechanism.
Choice B rationale:
Hyperglycemia is not associated with cold stress. Instead, hypoglycemia (low blood sugar) is a concern in newborns experiencing cold stress as they deplete their glucose stores to maintain body temperature.
Choice C rationale:
Metabolic alkalosis is not a priority assessment finding for cold stress. Metabolic acidosis (not listed in the options) can be associated with cold stress due to increased anaerobic metabolism, but it is not one of the provided choices.
Choice D rationale:
Hypoglycemia is a priority assessment finding associated with cold stress. As the baby's body uses glucose to produce heat from burning brown fat, it can lead to a drop in blood sugar levels, which is a significant concern in newborns.
Choice E rationale:
Metabolic acidosis is not listed among the provided choices, but it can be associated with cold stress due to the increased production of lactic acid from anaerobic metabolism when trying to generate heat.
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