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","B","C"]
Explanation
Choice A rationale: Primigravida
Primigravida (first-time pregnancy) is a known risk factor for preeclampsia. Studies show that nulliparous individuals (those who have never given birth before) have a higher likelihood of developing preeclampsia compared to multiparous individuals. The exact reason is not fully understood, but it is thought that immunological adaptation plays a role.
Choice B rationale: Age
Advanced maternal age (≥35 years) is a recognized risk factor for preeclampsia. This client is 36 years old, which places her in the higher-risk category. Older maternal age is associated with increased vascular dysfunction and underlying chronic conditions that predispose individuals to preeclampsia.
Choice C rationale: Type 1 diabetes mellitus
Type 1 diabetes mellitus significantly increases the risk of preeclampsia due to its impact on vascular health. Diabetes affects endothelial function and can cause chronic inflammation, both of which contribute to hypertension and proteinuria, hallmark symptoms of preeclampsia. Additionally, diabetes increases the risk of abnormal placentation, further raising the chances of hypertensive disorders in pregnancy.
Choice D rationale: Hemoglobin level
A hemoglobin level of 12.5 g/dL is within the normal range and does not contribute to an increased risk for preeclampsia. While anemia is sometimes associated with preeclampsia, a normal hemoglobin level does not raise concern in this case. Therefore, hemoglobin is not a risk factor for preeclampsia in this patient.
Correct Answer is A
Explanation
Choice A rationale
Completely saturating a perineal pad within 15 minutes indicates excessive postpartum bleeding, which is most commonly caused by uterine atony (failure of the uterus to contract effectively after delivery). Massaging the fundus stimulates uterine muscles to contract, helping to compress blood vessels at the placental site and control bleeding. This is the priority intervention to prevent further blood loss and potential hemorrhage.
Choice B rationale
Assessing vital signs is important to evaluate the extent of blood loss and the woman's hemodynamic stability. However, the immediate priority is to address the cause of the excessive bleeding by promoting uterine contraction. Vital sign assessment should follow fundal massage.
Choice C rationale
Calling the primary health care provider is necessary to report the excessive bleeding and implement further management if fundal massage is not effective. However, the nurse's immediate action should be to address the likely cause of the bleeding through fundal massage.
Choice D rationale
Initiating an intravenous (IV) infusion of Ringer's lactate solution may be necessary to restore fluid volume if significant blood loss has occurred or continues. However, the immediate priority is to stop the bleeding by promoting uterine contraction through fundal massage. IV fluids are a subsequent intervention to support hemodynamic stability.
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