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.

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Correct Answer is A

Explanation

A) Excessive uterine bleeding: A distended bladder can cause the uterus to become displaced to the right, preventing it from contracting effectively. This lack of uterine contraction can lead to uterine atony, which is a significant risk factor for excessive postpartum bleeding. When the uterus cannot contract well, it may result in continued
hemorrhage, which is a serious and immediate concern for postpartum patients.

B) A bladder rupture: While bladder rupture is a rare and severe complication, it is unlikely to occur in this situation. Bladder distention is a concern, but the most immediate danger is related to the uterus, not the bladder itself. A rupture would require significant trauma or extreme overdistention of the bladder, neither of which are described here.
C) Bladder wall atony: Bladder wall atony, where the bladder loses its ability to contract and expel urine, is not the most serious immediate consequence of bladder distention postpartum. While it may be uncomfortable and problematic, the main concern in this scenario is how bladder distention affects uterine contraction, which can lead to excessive bleeding.

D) Urinary tract infection: Although urinary retention can increase the risk of urinary tract infections (UTIs) due to incomplete bladder emptying, this is a less immediate and life-threatening concern compared to excessive bleeding. The primary concern in the immediate postpartum period is the potential for hemorrhage from uterine atony, which is worsened by bladder distention.

A. Don't do anything, this is a normal finding B. Check the infant's 02 sat C. Call the MD for referral D. Put socks and mittens on the infant to keep them warm

Correct Answer is B

Explanation

A) Don't do anything, this is a normal finding:
While it's true that acrocyanosis (bluish-purple discoloration of the hands and feet) can be a normal finding in the first 24-48 hours of life due to immature circulation, it’s important to assess the severity of the condition and rule out more serious causes. Just ignoring it without assessing the infant’s oxygenation status could lead to missing a potential respiratory issue.

B) Check the infant's O2 sat:
The most appropriate action is to assess the infant’s oxygen saturation levels. Acrocyanosis is typically benign and resolves on its own, but persistent cyanosis or a drop in oxygen saturation could indicate a more serious issue, such as respiratory distress or congenital heart disease. A pulse oximeter is a non-invasive tool that can help determine whether the infant’s oxygenation is adequate. This would help guide further clinical decisions.
C) Call the MD for referral:
Calling the doctor should only be considered if the baby’s oxygen saturation levels are low, or if other concerning symptoms (like poor feeding, lethargy, or significant difficulty breathing) are present. If the O2 saturation is normal, there’s no immediate need for referral. The key is to assess first before escalating to the provider.

D) Put socks and mittens on the infant to keep them warm:
Although providing warmth can help with maintaining body temperature, simply putting socks and mittens on the baby is not sufficient to rule out respiratory issues or other causes of cyanosis. If the infant’s oxygen saturation is normal and the baby is otherwise stable, this may be appropriate. However, checking the O2 saturation first is the correct step to ensure that no underlying respiratory problems are contributing to the cyanosis.

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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?

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Correct Answer is A

Explanation

You are assessing the baby and notice that their hands and feet are bluish-purple. You:

Correct Answer is B

Explanation

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