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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Hydralazine decreases blood pressure by vasodilation, improving renal perfusion and function. Enhanced kidney function promotes diuresis, balancing fluid levels and reducing hypertension.
Choice B rationale
While controlling blood pressure indirectly benefits liver health, hydralazine's primary effect on vasodilation does not directly support liver function.
Choice C rationale
Hydralazine primarily lowers blood pressure through vasodilation. Preventing arrhythmias is more directly associated with medications affecting cardiac conduction rather than vasodilators.
Choice D rationale
Lowering cholesterol levels is not a direct effect of hydralazine. Its primary action is reducing blood pressure through vascular smooth muscle relaxation, decreasing hypertension.
Correct Answer is C
Explanation
Choice A rationale
Phytonadione (vitamin K1) is not administered to improve dietary intake. Newborns receive it to prevent vitamin K deficiency bleeding, as they have low levels of vitamin K at birth due to limited placental transfer.
Choice B rationale
Phytonadione does not stimulate the immune system. It is a fat-soluble vitamin essential for the synthesis of clotting factors, which prevents bleeding disorders in newborns.
Choice C rationale
Newborns are given phytonadione to prevent hemorrhagic disorders, which can occur due to their immature liver's inability to produce sufficient clotting factors without adequate vitamin K.
Choice D rationale
While phytonadione supports liver function indirectly by aiding clotting factor synthesis, its primary role is to prevent hemorrhagic disease of the newborn, not directly to help an immature liver develop.
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