Nokea
A pregnant client asks the nurse to explain the meaning of cephalopelvic disproportion. Which explanation should the nurse give to the client?
- A. It means a large for gestational age fetus.
- B. It is the narrow opening between the ischial spines.
- C. There is an uneven size between the fetus presenting part and the pelvis.
- D. The shape of the pelvis is an android shape and is unfavorable for vaginal delivery.
Correct Answer: C
Rationale: Cephalopelvic disproportion means a disproportion (or uneven size) between the fetus presenting part and the maternal pelvis. It does not mean a large for gestational age fetus or that the pelvis is an android shape. The narrow opening between the ischial spines is called the transverse measurement.
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Which term is defined as a vaguely outlined area of edematous tissue situated over the portion of the scalp that presents in a vertex delivery?
- A. Hydrocephalus
- B. Cephalhematoma
- C. Caput succedaneum
- D. Subdural hematoma
Correct Answer: C
Rationale: Caput succedaneum is defined as a vaguely outlined area of edematous tissue situated over the portion of the scalp that presents in a vertex delivery. The swelling consists of serum or blood (or both) accumulated in the tissues above the bone, and it may extend beyond the bone margin. Hydrocephalus is caused by an imbalance in production and absorption of cerebrospinal fluid. When production exceeds absorption, fluid accumulates within the ventricular system, causing dilation of the ventricles. A cephalhematoma has sharply demarcated boundaries that do not extend beyond the limits of the (bone) suture line. A subdural hematoma is located between the dura and the cerebrum. It should not be visible on the scalp.
Which finding on a newborn assessment should the nurse recognize as suggestive of a clavicle fracture?
- A. Positive scarf sign
- B. Asymmetric Moro reflex
- C. Swelling of fingers on affected side
- D. Paralysis of affected extremity and muscles
Correct Answer: B
Rationale: A newborn with a broken clavicle may have no signs. The Moro reflex, which results in sudden extension and abduction of the extremities followed by flexion and adduction of the extremities, will most likely be asymmetric. The scarf sign that is used to determine gestational age should not be performed if a broken clavicle is suspected. Swelling of the fingers on the affected side and paralysis of the affected extremity and muscles are not signs of a fractured clavicle.
A mother is upset because her newborn has erythema toxicum neonatorum. The nurse should reassure her that this is what?
- A. Easily treated
- B. Benign and transient
- C. Usually not contagious
- D. Usually not disfiguring
Correct Answer: B
Rationale: Erythema toxicum neonatorum, or newborn rash, is a benign, self-limiting eruption of unknown cause that usually appears within the first 2 days of life. The rash usually lasts about 5 to 7 days. No treatment is indicated. Erythema toxicum neonatorum is not contagious. Successive crops of lesions heal without pigmentation.
What is an important nursing intervention for a full-term infant receiving phototherapy?
- A. Observing for signs of dehydration
- B. Using sunscreen to protect the infants skin
- C. Keeping the infant diapered to collect frequent stools
- D. Informing the mother why breastfeeding must be discontinued
Correct Answer: A
Rationale: Dehydration is a potential risk of phototherapy. The nurse monitors hydration status to be alert for the need for more frequent feedings and supplemental fluid administration. Lotions are not used; they may contribute to a frying effect. The infant should be placed nude under the lights and should be repositioned frequently to expose all body surfaces to the lights. Breastfeeding is encouraged. Intermittent phototherapy may be as effective as continuous therapy. The advantage to the mother and father of being able to hold their infant outweighs the concerns related to clearance.
The nurse is caring for an infant who will be discharged on home phototherapy. What instructions should the nurse include in the discharge teaching to the parents?
- A. Apply an oil-based lotion to the infants skin two times per day to prevent the skin from drying out under the phototherapy light.
- B. Keep the eye shields on the infants eyes even when the phototherapy light is turned off.
- C. Take the infants temperature every 2 hours while the newborn is under the phototherapy light.
- D. Make a follow-up visit with the health care provider within 2 or 3 days after your infant has been on phototherapy.
Correct Answer: D
Rationale: With short hospital stays, infants may be discharged with a prescription for home phototherapy. It is the responsibility of the nurse planning discharge to include important information such as the need for a follow-up visit with the health care provider in 2 or 3 days to evaluate feeding and elimination pattern and to have blood work done if needed. The parents should be taught to not apply oil or lotions to prevent increased tanning; the babys eye shields can come off when the phototherapy lights are turned off, and the infants temperature needs to be monitored but not taken every 2 hours.