The nurse is assessing a one hour old newborn delivered vaginally after a 15 hour labor. Upon palpation of the head, the nurse notices swelling of the tissue over the presenting part of the infant's head, crossing the suture lines. How would the nurse document this finding?

Caput succedaneum present.

Severe molding present.

Cephalhematoma present.

Fontanels soft and flat.

Answer and Explanation

The Correct Answer is A

A) Caput succedaneum present:
Caput succedaneum refers to the swelling of the soft tissues on the newborn's head, typically caused by the pressure exerted during vaginal delivery. This condition is often seen after a prolonged labor or in cases of vacuum-assisted delivery. It presents as a soft, fluid-filled swelling that crosses the suture lines, which distinguishes it from a cephalhematoma (a collection of blood). This swelling is usually benign and resolves within a few days after birth without intervention.

B) Severe molding present:
Molding refers to the shaping of the newborn's skull bones as they overlap to pass through the birth canal during delivery. It typically presents as elongated or asymmetric head shapes, particularly in the vertex presentation. Severe molding would not involve swelling of the soft tissues and would not cross the suture lines. This term is typically used to describe changes in the shape of the skull bones rather than soft tissue swelling.

C) Cephalhematoma present:
A cephalhematoma is a collection of blood between the newborn's skull and the periosteum (the membrane covering the bones). Unlike caput succedaneum, a cephalhematoma does not cross the suture lines because the blood is confined to the area overlying the affected bone. Cephalhematomas are typically the result of trauma during delivery, such as forceps or vacuum extraction. The swelling in a cephalhematoma is firmer and does not appear as soft or fluid-filled as caput succedaneum.

D) Fontanels soft and flat:
The fontanels are the soft spots on the baby’s head where the skull bones have not yet fused. The anterior fontanel is usually the most prominent, and the posterior fontanel is much smaller. While fontanels should be soft and flat in the early stages, this option doesn't describe the swelling or soft tissue findings as described in the question. The soft, fluid-filled swelling over the head would be more indicative of caput succedaneum rather than a normal fontanel finding.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Mother Rh-, baby Rh+:
Rh immune globulin (RhoGAM) is given to Rh-negative mothers after childbirth if the baby is Rh-positive. This is to prevent the mother from developing antibodies against Rh-positive blood cells, which could affect future pregnancies. If the mother’s immune system recognizes Rh-positive cells as foreign, it may start producing antibodies that can cross the placenta and harm future Rh-positive fetuses, potentially leading to hemolytic disease of the newborn. Administering RhoGAM prevents this sensitization from occurring.

B. Mother Rh-, baby Rh-:
If the mother is Rh-negative and the baby is also Rh-negative, there is no risk of Rh incompatibility. Since there is no Rh-positive blood in the mix, the mother will not develop antibodies against Rh-positive cells. Therefore, Rh immune globulin is not needed in this situation.

C. Mother Rh+, baby Rh+:
If the mother is Rh-positive, there is no risk of Rh incompatibility regardless of the baby’s Rh status. Rh-positive mothers do not produce antibodies against Rh-positive blood cells, so RhoGAM is unnecessary in this scenario.

D. Mother Rh+, baby Rh-:
Again, since the mother is Rh-positive, there is no risk of sensitization, even if the baby is Rh-negative. In this situation, the mother's immune system will not generate antibodies against Rh-negative blood cells, and RhoGAM is not needed.

A. Apply ice to the perineal area for the first 12-24 hours. B. Apply warm packs to the perineal area for the first 24-48 hours. C. Encourage sitz baths at least twice a day D. Use a topical antiseptic cream or spray on the perineal area. E. Obtain an order for an indwelling urinary catheter.

Correct Answer is ["A","C"]

Explanation

A) Apply ice to the perineal area for the first 12-24 hours:
Applying ice to the perineal area in the first 12-24 hours after delivery is a common intervention for promoting comfort, especially for lacerations or episiotomies. The cold helps to reduce swelling and inflammation, and it numbs the area, providing pain relief. Ice also helps to constrict blood vessels, reducing blood flow to the affected area, which can prevent excessive bleeding and promote healing.

B) Apply warm packs to the perineal area for the first 24-48 hours:
Warm packs are generally not used in the first 24-48 hours after delivery for a laceration. Heat can increase blood flow, which is not ideal immediately after birth when the risk of swelling and bleeding is higher. Typically, warm packs are more beneficial after the first 48 hours to improve circulation and promote healing. Therefore, this is not the best intervention in the immediate postpartum period for a labial laceration.

C) Encourage sitz baths at least twice a day:
Sitz baths are highly effective for postpartum comfort, particularly for perineal trauma such as lacerations or episiotomies. A sitz bath helps to cleanse the area and promote relaxation, reducing discomfort. It also enhances circulation to the perineum, which can speed up healing. Encouraging sitz baths at least twice a day is a helpful intervention for postpartum care and is appropriate for a labial first-degree laceration.

D) Use a topical antiseptic cream or spray on the perineal area:
While topical antiseptics may help reduce infection risk, they are generally not necessary for most first-degree lacerations, especially if they are uncomplicated. In fact, overuse of antiseptics or antibiotic creams can irritate the sensitive tissue in the perineal area and delay healing. The focus should be on keeping the area clean and dry, using gentle care. Therefore, this intervention is not typically recommended for a labial laceration.

E) Obtain an order for an indwelling urinary catheter:
An indwelling urinary catheter is usually only needed in specific cases, such as when a woman is unable to void postpartum due to perineal trauma, epidural anesthesia, or bladder retention. In the case of a labial first-degree laceration, there is no indication for an indwelling catheter unless the woman is unable to void on her own. The best approach is to encourage frequent voiding and assist with comfortable positioning.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is assessing a one hour old newborn delivered vaginally after a 15 hour labor. Upon palpation of the head, the nurse notices swelling of the tissue over the presenting part of the infant's head, crossing the suture lines. How would the nurse document this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Rh, immune globulin will be ordered after birth if which situation occurs?

Correct Answer is A

Explanation

Which of the following nursing interventions will promote comfort for a client with a labial first degree laceration? Select all that apply.

Correct Answer is ["A","C"]

Explanation

A breastfeeding woman develops engorged breasts at 3 days postpartum. What action would help this woman achieve her goal of reducing the engorgement? The woman:

The laboratory results for a postpartum woman are as follows: blood type: A + rubella: non-immune hematocrit: 30% GBS: negative How would the nurse best interpret these data?

The nurse is teaching a newborn care class to parents who are about to give birth to their first babies. Which statement indicates that teaching was effective?

You know that infant safety is important so which of the following should be in place to maintain infant safety:

Which documentation on a woman's chart after postpartum day 14 indicates a normal involution process?

A postpartum client is to receive the Rubella vaccine prior to discharge from the hospital. Why is she instructed to not become pregnant for 4 weeks after receiving this vaccine?

A postpartum woman telephones about her 6-day-old infant. She is not scheduled for, weight check until the infant is 10 days old, and she is worried about whether breastfeeding going well. Effective breastfeeding is best indicated by the newborn who: