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 C

Explanation

Choice A rationale

Administering acetaminophen is not indicated as the temperature of 100.4° F (38° C) is within the normal postpartum range, often due to dehydration or breast engorgement. Acetaminophen should be used cautiously and only if necessary.

Choice B rationale

Assessing perineum for excessive lochia is unnecessary here, as the current vital signs do not indicate hemorrhage. Normal postpartum bleeding gradually decreases in amount and should be monitored accordingly but not prompted by these vitals.

Choice C rationale

Documentation of vital signs is essential to maintain accurate medical records and track any changes in the patient's condition. Accurate records help in identifying trends and making informed decisions about patient care.

Choice D rationale

Reporting a heart rate of 58 beats/minute is unnecessary because bradycardia can be normal in postpartum women, especially if they have good cardiovascular fitness. It is important to monitor for other symptoms before taking further action.

A. Visualization of implantation by vaginal ultrasound. B. Maternal blood serum tests positive for alpha-fetoprotein. C. Presence of amenorrhea for 2 months. D. Reports feeling tired all of the time.

Correct Answer is A

Explanation

Choice A rationale

Visualization of implantation by vaginal ultrasound offers the highest accuracy in confirming pregnancy, as it directly visualizes the implanted embryo, eliminating errors associated with biochemical tests.

Choice B rationale

Maternal blood serum tests positive for alpha-fetoprotein do not confirm pregnancy. Alpha-fetoprotein is a marker used primarily for screening fetal abnormalities, not pregnancy determination.

Choice C rationale

The presence of amenorrhea for 2 months can suggest pregnancy but is not definitive due to other potential causes of missed periods, such as hormonal imbalances or stress, reducing its accuracy.

Choice D rationale

Reporting feeling tired all the time is a nonspecific symptom that can result from numerous conditions unrelated to pregnancy, making it an unreliable method for pregnancy determination.

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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

The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4° F (38° C), heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74 mm Hg. Which action should the nurse implement?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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