During the admission of a newborn, the nurse identifies a localized swelling that does not cross the suture line on the posterior area of the parietal bone. Which action should the nurse implement?

Apply direct pressure to the caput succedaneum.

Submit a request for a STAT Computerized Tomography (CT) scan of the head.

Notify the pediatrician of the cephalhematoma.

Assess neurological vital signs every 4 hours.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Caput succedaneum is a benign, self-limiting condition and does not require direct pressure. It resolves on its own within a few days after birth. Applying pressure may cause unnecessary discomfort to the newborn.

Choice B rationale

A STAT CT scan of the head is not necessary for diagnosing cephalhematoma, which is a localized collection of blood between the skull and periosteum. CT scans are typically reserved for more severe neurological concerns.

Choice C rationale

A cephalhematoma, characterized by swelling that does not cross suture lines, requires notification of the pediatrician. It may increase the risk of hyperbilirubinemia and needs monitoring for potential complications.

Choice D rationale

While assessing neurological vital signs every 4 hours is important for overall newborn care, it does not address the specific condition of cephalhematoma. The primary concern is monitoring for complications such as jaundice.

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Correct Answer is B

Explanation

Choice A rationale

Starting oxytocin infusion immediately may cause uterine hyperstimulation in clients who have already responded to misoprostol. Close monitoring and spacing out uterotonic agents help prevent adverse effects like uterine tachysystole and fetal distress.

Choice B rationale

Beginning oxytocin 4 hours after misoprostol ensures sufficient time for cervical ripening and reduces the risk of uterine hyperstimulation. This allows for safer labor induction and better outcomes for both mother and fetus.

Choice C rationale

Ambulating the client after misoprostol administration is generally safe but doesn't address the need for controlled uterotonic administration. Monitoring and timing of further uterotonics are crucial to avoid adverse effects and ensure safe induction.

Choice D rationale

Administering misoprostol every 2 hours is not recommended due to the risk of uterine hyperstimulation. It’s important to follow safe dosing intervals to reduce the risk of complications such as uterine tachysystole and fetal compromise.

A. Obtain a blood sample for complete blood count. B. Infuse 1,000 mL normal saline using a large bore intravenous (IV) catheter. C. Palpate the abdomen for contractions. D. Tilt the backboard sideways to displace the uterus laterally.

Correct Answer is D

Explanation

Choice A rationale

Obtaining a blood sample for complete blood count is crucial but secondary. The client’s low blood pressure and high heart rate indicate possible hypovolemia requiring immediate intervention to restore blood pressure and perfusion.

Choice B rationale

Infusing normal saline helps restore blood volume. However, it won't address supine hypotension syndrome, caused by uterine compression of the inferior vena cava, which necessitates repositioning the client first to improve hemodynamic stability.

Choice C rationale

Palpating the abdomen for contractions is important in assessing labor progress. Yet, it doesn't address the immediate hemodynamic instability caused by supine hypotension, which needs immediate correction to avoid fetal compromise.

Choice D rationale

Tilting the backboard laterally displaces the uterus off the inferior vena cava, alleviating supine hypotension syndrome. This improves maternal blood pressure and fetal perfusion, addressing the immediate hemodynamic instability effectively.

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During the admission of a newborn, the nurse identifies a localized swelling that does not cross the suture line on the posterior area of the parietal bone. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A primigravida client with gestational hypertension and a Bishop score of 3 is scheduled for induction of labor. The nurse administers misoprostol at 0700, then observes regular contractions with cervical changes at 0900. Which action should the nurse take?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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