Infants in whom cephalohematomas develop are at increased risk for:
Caput succedaneum.
Jaundice.
Infection.
Erythema toxicum.
The Correct Answer is B
Choice A rationale
Caput succedaneum is swelling of the soft tissues of the newborn's scalp, often caused by pressure during vaginal delivery. It is a separate condition from cephalohematoma, which involves bleeding between the periosteum and the skull bone. Therefore, cephalohematoma does not increase the risk for caput succedaneum.
Choice B rationale
Jaundice, or hyperbilirubinemia, is a common condition in newborns due to the breakdown of fetal red blood cells and the immature liver's inability to efficiently process bilirubin. Cephalohematomas involve the rupture of blood vessels, leading to an increased breakdown of red blood cells. This releases more bilirubin into the bloodstream, thus elevating the risk of jaundice in infants with cephalohematomas. Normal total bilirubin levels in newborns range from 1 to 12 mg/dL, varying with age in days.
Choice C rationale
Infection is a risk associated with any break in the skin or invasive procedure, but a cephalohematoma itself is a collection of blood beneath the periosteum and does not inherently create an open wound or direct pathway for infection. While infection of a cephalohematoma is possible, it is not a primary increased risk associated with its development.
Choice D rationale
Erythema toxicum is a common, benign skin rash seen in newborns, characterized by small, yellow-white papules or pustules surrounded by red skin. Its etiology is unknown but it is thought to be an inflammatory reaction of the hair follicles. It is not related to the presence or development of a cephalohematoma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Pounding headache, visual changes, and epigastric pain in a patient with pregnancy-induced hypertension (PIH), now known as gestational hypertension or preeclampsia, are classic signs of worsening disease and indicate central nervous system irritability and potential hepatic involvement. These symptoms suggest the condition is progressing towards severe preeclampsia and increase the risk of eclampsia, which is characterized by seizures.
Choice B rationale
Magnesium sulfate is used to prevent seizures in severe preeclampsia. While it can cause side effects such as flushing, warmth, and muscle weakness, it does not typically cause pounding headache, visual changes, or epigastric pain. These symptoms are more indicative of the underlying disease process rather than the treatment.
Choice C rationale
Anxiety due to hospitalization can cause various symptoms, but the specific combination of pounding headache, visual changes, and epigastric pain is more strongly associated with the physiological changes occurring in worsening preeclampsia rather than solely psychological distress.
Choice D rationale
Gastrointestinal upset can cause epigastric pain, but it would not typically be accompanied by pounding headache and visual changes in the context of pregnancy-induced hypertension. The constellation of these symptoms strongly points towards a worsening of the hypertensive condition and potential end-organ involvement. .
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
The nurse should anticipate a provider prescription for pyridoxine due to the client’s severe dehydration.
Rationale for correct answers
Pyridoxine (vitamin B6) is recommended for nausea and vomiting in pregnancy (NVP), commonly known as hyperemesis gravidarum (HG), especially in patients with persistent symptoms leading to dehydration. Severe dehydration is confirmed by elevated urine specific gravity (normal: 1.002–1.030), low sodium (normal: 135–145 mEq/L), and positive ketones, indicating excessive vomiting and malnutrition.
Rationale for incorrect Response 1 options
- Antibiotics: There is no evidence of infection; urinalysis and WBC count are within normal limits.
- Magnesium sulfate: Used for eclampsia or preterm labor prevention, not for HG.
- Oxytocin: Stimulates uterine contractions and is contraindicated during early pregnancy unless labor induction is required.
Rationale for incorrect Response 2 options
- Urinary tract infection: No leukocytes or nitrites in urine, and WBC count is normal (4,500–11,000/mm³).
- Preeclampsia: No proteinuria or hypertension (≥140/90 mm Hg).
- Preterm labor: No uterine contractions or cervical changes.
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