Nokea
Edward, a newborn delivered at 41 weeks' gestation, weighs 10 lb 4 oz. Vaginal delivery for this G1P1 mother was assisted with forceps. The nurse is completing her assessment and notes a sharply demarcated swelling over the parietal bones. The occipital and frontal skull bones are not affected. The neck does not appear edematous and is soft to the touch with full mobility. The infant is awake and active and has been breast-feeding well. What is the most probable cause of the swelling?
- A. cephalohematoma
- B. subgaleal hemorrhage
- C. caput succedaneum
- D. skull fracture
Correct Answer: A
Rationale: Cephalohematoma involves localized bleeding beneath the periosteum, typically over a single bone.
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When the nurse determines they have a high-risk newborn and birthing person in their care, what can they do to mitigate the situation?
- A. Document in the chart.
- B. Reassure the parent that everything will be fine.
- C. Refer the couplet to social work for early intervention.
- D. Refer to a pediatric health-care provider for well-baby checkup.
Correct Answer: C
Rationale: Referring to social work ensures early intervention and support for high-risk situations.
The nurse is completing a gestational assessment on a newborn whose parent was treated for preeclampsia during labor. The neonate is demonstrating 'frog-like' posturing. The nurse knows this is likely due to what medication during labor?
- A. fentanyl in the epidural
- B. penicillin for treatment of group B strep infection
- C. magnesium sulfate for treatment of preeclampsia
- D. prenatal vitamins
Correct Answer: C
Rationale: The correct answer is C: magnesium sulfate for treatment of preeclampsia. Magnesium sulfate is commonly used to manage preeclampsia in pregnant women. Neonates born to mothers who received magnesium sulfate may exhibit 'frog-like' posturing due to the effects of the medication crossing the placenta. The other choices, A: fentanyl in the epidural, B: penicillin for treatment of group B strep infection, and D: prenatal vitamins, are not associated with causing 'frog-like' posturing in newborns. Fentanyl in the epidural is a pain medication, penicillin is an antibiotic, and prenatal vitamins are supplements that do not typically cause this specific posturing.
The nurse provides discharge instructions to a parent about umbilical cord care. What statement by the parent indicates effective health teaching?
- A. My child can have a tub bath every day.'
- B. I will clean the stump with antiseptics daily.'
- C. Water and soap can be used if the stump is dirty.'
- D. I need to apply an antibiotic ointment every day.'
Correct Answer: C
Rationale: Step 1: Using water and soap if the stump is dirty is the correct method for umbilical cord care as per current guidelines.
Step 2: Soap and water help prevent infection without disrupting the natural healing process.
Step 3: Daily tub baths or using antiseptics or antibiotic ointments can be harmful by interfering with healing.
Step 4: Therefore, choice C is the most appropriate and effective method for umbilical cord care.
How can the nurse be culturally sensitive after a neonatal death?
- A. Call a priest for all families during this time of grief.
- B. Recognize that most religions have traditions surrounding death.
- C. Encourage families to have an open casket to help them deal with the death.
- D. Discuss cremation, as it is the best process for a neonatal death.
Correct Answer: B
Rationale: Recognizing religious traditions acknowledges cultural diversity and respects individual beliefs. Imposing specific practices, such as calling a priest or promoting cremation, disregards personal preferences and cultural norms.
The nurse holds an infant upright and allows his feet to brush the surface of the examination table. Which of the following is the normal reflex response to this stimulation?
- A. Draws legs up tight against the lower abdomen
- B. Extends legs straight against the pressure
- C. Makes stepping actions with both feet
- D. Toes curl in then fan outward symmetrically
Correct Answer: C
Rationale: The stepping reflex occurs when the infant is held upright and his or her feet brush a horizontal surface distal to the feet. Drawing the legs up tight against the lower abdomen would be an abnormal response. Extending the legs against pressure is a positive magnet reflex. Curling the toes in, then fanning them outward, is a positive Babinski reflex.