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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Applying crushed cabbage leaves to the breasts can be a traditional remedy to help reduce swelling and discomfort associated with engorgement.
Choice B rationale:
Wearing a snug-fitting bra can help provide support to the breasts and reduce discomfort from breast engorgement. It can also help to avoid stimulation of the breasts, which can decrease milk production in a client who is not breastfeeding. This is an appropriate comfort measure for the client.
Choice C rationale:
Stimulating the nipples by squeezing softly can lead to increased milk production and exacerbate breast engorgement. For a client who is not breastfeeding, this action is not recommended and may worsen the engorgement.
Choice D rationale:
Applying ice packs to the breasts can help reduce inflammation and alleviate discomfort from breast engorgement. This is an appropriate comfort measure for the client who is not breastfeeding.
Correct Answer is B
Explanation
"Baby powder will help prevent a diaper rash.”.
Choice A rationale:
"I will use mild soap”. indicates an appropriate understanding of newborn bathing. Mild soap is suitable for newborn skin to avoid irritation.
Choice B rationale:
This is the correct answer. Baby powder is not recommended for newborns as it can cause respiratory issues when inhaled and may lead to skin irritation. Therefore, the client needs further teaching about the use of baby powder.
Choice C rationale:
"I will test the water on my wrist for temperature before bathing”. demonstrates proper safety measures, ensuring the water is not too hot for the baby.
Choice D rationale:
"I will use a basin during bathing”. is a reasonable approach to bathing the newborn and does not indicate a need for further teaching.
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