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A nurse is assessing a newborn who was born vaginally with vacuum extractor assistance. The nurse notes swelling over the newborn's head that crosses the suture line. The nurse should identify the swelling as which of the following findings?
- A. Nevus flammeus.
- B. Caput succedaneum.
- C. Cephalohematoma.
- D. Erythema toxicum.
Correct Answer: B
Rationale: Caput succedaneum involves swelling of the scalp caused by pressure during delivery, often crossing suture lines due to subcutaneous fluid accumulation, a hallmark distinguishing it from other neonatal head conditions.
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A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations of the FHR. Which of the following actions should the nurse take first?
- A. Prepare the necessary equipment to initiate an amnioinfusion.
- B. Assist with performing a vaginal/speculum exam to check for a prolapsed umbilical cord.
- C. Discontinue the infusion of oxytocin.
- D. Provide instructions for the client about potential preparation for birth.
Correct Answer: C
Rationale: Discontinuing oxytocin reduces uterine contractions, alleviating cord compression and improving fetal oxygenation, which is the first step in managing recurrent variable decelerations of fetal heart rate.
A nurse is assessing a client who gave birth 1 week ago. The client states, 'I don't know what's wrong. I love my baby, but I feel so let down and I seem to cry for no reason.' The nurse should identify that the client is experiencing which of the following emotional responses to birth?
- A. Postpartum depression.
- B. Taking-in phase.
- C. Postpartum blues.
- D. Taking-hold phase.
Correct Answer: C
Rationale: Postpartum blues, characterized by mood swings, crying spells, and irritability, typically resolve within two weeks postpartum and are linked to hormonal changes.
A nurse is caring for a client who gave birth 4 hr ago and is experiencing excessive vaginal bleeding. Which of the following actions should the nurse plan to take first?
- A. Elevate the client's legs to a 30° angle.
- B. Insert an indwelling urinary catheter.
- C. Massage the client's fundus.
- D. Initiate an infusion of oxytocin.
Correct Answer: C
Rationale: Massaging the fundus promotes uterine contraction, which is the first-line intervention to control postpartum hemorrhage caused by uterine atony.
A newborn born two hours ago at 36 weeks gestation has noted findings. Which findings are consistent with neonatal jaundice?
- A. Bruising noted over occiput.
- B. Yellowish hue on sclera and skin blanching.
- C. Transcutaneous bilirubin level 12.5 mg/dL (less than 12 mg/dL).
- D. Phototherapy initiated at 08:45.
Correct Answer: B,C,D
Rationale: Yellowish sclera and blanching skin (B), transcutaneous bilirubin level of 12.5 mg/dL (C), and phototherapy initiation (D) indicate neonatal jaundice from elevated bilirubin levels due to immature hepatic conjugation, requiring monitoring and treatment to prevent kernicterus.
A nurse is assessing a newborn whose mother had gestational diabetes mellitus. Which of the following findings should the nurse identify as a manifestation of hypoglycemia?
- A. Jitteriness.
- B. Hypertonia.
- C. Acrocyanosis of the hands.
- D. Generalized petechiae.
Correct Answer: A
Rationale: Jitteriness indicates hypoglycemia in newborns as glucose is critical for neonatal brain function. Blood glucose less than 45 mg/dL supports this diagnosis, requiring prompt intervention to avoid neurological harm.