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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Monitor the newborn for signs of jaundice and anemia.

This is because the newborn has a positive Coombs test, which means that there are antibodies against the newborn’s red blood cells (RBCs) in the blood.

These antibodies can cause hemolysis (destruction) of the RBCs, leading to jaundice (yellowing of the skin and eyes due to high bilirubin levels) and anemia (low RBC count and hemoglobin levels).The most likely cause of the positive Coombs test in this case is ABO incompatibility, which occurs when the mother has type O blood and the newborn has type A or B blood.

Choice A is wrong because administering hepatitis B immune globulin (HBIG) to the newborn within 12 hours of birth is indicated for newborns whose mothers are positive for hepatitis B surface antigen (HBsAg), which is not the case here.

Choice C is wrong because obtaining a blood sample from the newborn for blood typing and crossmatching is not necessary, as the newborn’s blood type is already known to be A positive.

Choice D is wrong because preparing the newborn for exchange transfusion with type O negative blood is a treatment option for severe cases of hemolytic disease of the newborn (HDN), which is not evident in this scenario.Exchange transfusion involves replacing the newborn’s blood with donor blood to remove antibodies and bilirubin.

A. “If a newborn has a heart rate below 100 beats per minute, he will receive one point for heart rate.” B. “If a newborn has acrocyanosis, he will receive one point for color.” C. “If a newborn has active motion of extremities, he will receive two points for muscle tone.” D. “If a newborn has a vigorous cry when stimulated, he will receive two points for reflex irritability.”.

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.

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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?

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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?