A nurse is collecting data from a newborn and notes a swollen area on the head that does not cross the suture line. The nurse should document this finding as which of the following?
Cephalhematoma.
Nevus flammeus.
Caput succedaneum.
Molding.
The Correct Answer is A
Choice A rationale:
Cephalhematoma is the correct answer because it presents as a swelling on the newborn's head confined to one cranial bone and does not cross suture lines. It usually resolves on its own within a few weeks to months but can increase the risk of jaundice due to the breakdown of red blood cells in the hematoma.
Choice B rationale:
Nevus flammeus, also known as a port-wine stain, is a type of vascular birthmark. It presents as a flat, pink, or red mark on the skin and does not involve swelling of the head. This choice is unrelated to the findings described in the question and is therefore incorrect.
Choice C rationale:
Caput succedaneum refers to a diffuse, soft tissue swelling of the scalp that does cross suture lines. It is caused by pressure on the head during delivery, leading to edema and bruising. It typically resolves within a few days after birth.
Choice D rationale:
Molding refers to the shaping of the fetal head during childbirth as it passes through the birth canal. It may cause temporary elongation or molding of the head, but it does not present as a localized swollen area. This choice is not applicable to the findings mentioned in the question and is thus incorrect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
Choice A rationale:
Wearing a supportive bra can actually help to manage engorgement, so it's not recommended to avoid wearing one during the day.
Choice B rationale:
Cold compresses are typically applied after feeding to reduce swelling, not before. Applying them before might hinder the milk let-down reflex.
Choice C rationale:
Frequent feeding can help to alleviate engorgement by ensuring that the breasts are being emptied regularly.
Choice D rationale:
Stopping breastfeeding until finishing antibiotics is not advisable, as it can lead to decreased milk supply and potential issues with engorgement. Antibiotics prescribed by a healthcare provider are usually safe to take while breastfeeding, and interrupting breastfeeding can exacerbate the engorgement problem. This choice is not appropriate for managing breast engorgement and is therefore incorrect.
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