While performing a physical assessment of a newborn boy, the nurse notes diffuse edema of the soft tissues of his scalp that crosses suture lines. The nurse documents this finding as:
cephalhematoma.
molding
microcephaly
caput succedaneum
The Correct Answer is D
A. Cephalhematoma refers to a collection of blood between the baby's skull and the periosteum (the membrane covering the bone), which does not cross the suture lines. It typically occurs after a traumatic delivery, but it is not diffuse edema like caput succedaneum.
B. Molding refers to the shaping of the baby’s head to fit through the birth canal during delivery. It involves temporary changes to the skull bones (such as overlapping sutures) but does not involve edema or soft tissue swelling.
C. Microcephaly is a condition where a newborn's head is abnormally small, usually due to developmental issues, and it has nothing to do with edema or swelling of the soft tissues.
D. Caput succedaneum is the correct term for diffuse edema of the newborn’s scalp that crosses the suture lines. It is caused by the pressure during delivery as the baby's head moves through the birth canal, and it typically resolves within a few days after birth.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Wrap the newborn in a blanket helps maintain body heat after the initial drying and stimulation but is not the first priority in thermoregulation.
B. Put a hat on the newborn's head also helps prevent heat loss, particularly from the head, which is a major site of heat loss in newborns. However, this should be done after drying to avoid trapping moisture.
C. Check the newborn's temperature is important but should be done after immediate measures to prevent heat loss have been taken.
D. Dry the newborn thoroughly is the first and most critical step in preventing evaporative heat loss, which is the primary cause of newborn heat loss immediately after birth. Removing wet amniotic fluid from the skin helps stabilize temperature effectively.
Correct Answer is D
Explanation
A. 25mg/hr is incorrect. The question asks for the volume in mL/hr, not the dose in milligrams per hour.
B. 25g/hr is incorrect. The ordered dose is 1g/hr, not 25g/hr.
C. 250mL/hr would provide a much higher dose than ordered, based on the concentration.
D. 25mL/hr is correct. This is the calculated volume to deliver the 1g/hr maintenance dose based on the supplied concentration. Volume= Ordered dose/ Concentration
Determine the concentration of the solution: The supplied concentration is 20g/500mL, which simplifies to 0.04g/mL (since 20g = 20,000mg and 500mL = 500mL).
Determine the ordered dose: The order is for a maintenance dose of 1g/hr.
Calculate the volume to be infused: 1/0.04= 25mL/hr
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