A nurse is caring for an infant who has a cephalohematoma on the left side of his skull.
Which of the following interventions should the nurse implement?
Monitor for signs of jaundice
Apply pressure dressing over the area
Administer antibiotics as prescribed
Elevate the head of the bed.
The Correct Answer is A
Monitor for signs of jaundice. A cephalohematoma is a collection of blood under the scalp that occurs due to trauma or pressure during delivery. It may increase the risk of jaundice in the newborn due to the breakdown of red blood cells and the release of bilirubin. Jaundice is a condition that causes yellowing of the skin and eyes due to high levels of bilirubin in the blood. Monitoring for signs of jaundice is important to prevent complications such as brain damage or kernicterus.
Apply pressure dressing over the area. This is wrong because applying pressure may increase the bleeding and cause more damage to the scalp and skull. A cephalohematoma does not require any treatment and usually resolves on its own within weeks or months.
Administer antibiotics as prescribed. This is wrong because antibiotics are not indicated for a cephalohematoma unless there is evidence of infection. Infection is a rare complication that may lead to osteomyelitis or meningitis. Antibiotics should be used only if prescribed by a doctor based on clinical signs and laboratory tests.
Elevate the head of the bed. This is wrong because elevating the head of the bed may not have any effect on a cephalohematoma. It may also cause discomfort or compromise the airway of the newborn. The position of the baby should be adjusted according to their comfort and safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This is wrong because acrocyanosis means that the body is pink but the extremities are blue, which indicates poor circulation.A normal Apgar score for color is two points, which means that the baby is pink all over.
Choice A is correct because a heart rate below 100 beats per minute is considered moderately abnormal and receives one point.
Choice C is correct because active motion of extremities indicates good muscle tone and receives two points.
Choice D is correct because a vigorous cry when stimulated indicates good reflex irritability and receives two points.
Correct Answer is A
Explanation
Thin and transparent skin is a sign of prematurity in newborns.The New Ballard Scale is a scale that estimates the gestational age of a newborn infant based on physical and neuromuscular characteristics.
The other choices are signs of maturity or postmaturity in newborns:
• Choice B: Well-developed breastbuds indicate a gestational age of 38 to 44 weeks.
• Choice C: Creases on the bottom of feet indicate a gestational age of 32 to 44 weeks.
• Choice D: Developed labia indicate a gestational age of 40 to 44 weeks.
The normal range for gestational age is 37 to 42 weeks.Premature infants are those born before 37 weeks, and postmature infants are those born after 42 weeks.
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