Nokea
The nursery nurse notes the presence of diffuse edema on a newborn babys head. Review of the birth record indicates that her mother experienced a prolonged labor and difficult childbirth. What action by the nurse is best?
- A. Document the findings in the infants chart.
- B. Measure head circumference every 12 hours.
- C. Prepare to administer IV osmotic diuretics.
- D. Transfer the baby to the NICU for monitoring.
Correct Answer: A
Rationale: Caput succedaneum is diffuse edema that crosses the cranial suture lines and disappears without treatment during the first few days of life. It often is the result of a traumatic or difficult birth. The nurse should document the findings. No other action is needed.
You may also like to solve these questions
A newborn that is a large-for-gestational-age (LGA) infant is in which percentile(s) for weight?
- A. Below the 90th
- B. Less than the 10th
- C. Greater than the 90th
- D. Between the 10th and 90th
Correct Answer: C
Rationale: The correct answer is C because a newborn classified as large-for-gestational-age (LGA) is above the 90th percentile for weight based on their gestational age. This means the infant's weight is greater than 90% of other infants of the same gestational age. Choices A and B are incorrect as they indicate being below the 90th percentile, which is not the case for an LGA infant. Choice D is also incorrect as an LGA infant's weight is specifically above the 90th percentile, not between the 10th and 90th percentile.
The perinatal nurse wants to contact the pediatrician about a heart murmur that was auscultated during a newborn assessment. During what time frame would hearing the murmur lead the nurse to contact the health-care provider?
- A. 8 to 12 hours
- B. 12 to 24 hours
- C. 24 to 48 hours
- D. 48 to 72 hours
Correct Answer: D
Rationale: It is not uncommon to hear murmurs in infants less than 24 hours old. Hearing a murmur after 48 hours indicates a need for further investigation
A home health nurse visits a 2-week-old infant and observes the umbilical cord has dried and fallen off. The area appears healed with no drainage or erythema present. Given these assessment findings, what instruction should the nurse give the parent?
- A. cover the umbilicus with a band-aid
- B. continue to clean the stump with alcohol for 1 week
- C. apply an antibiotic ointment to the stump
- D. give the baby a bath in an infant tub now
Correct Answer: D
Rationale: Once healed, the area can be submerged in water during baths.
The perinatal nurse notes that a newborn does not seem to have an opening inside the anal ring. Which action by the nurse takes priority?
- A. Ask the mother how well the infant is eating.
- B. Assess the abdomen and notify the physician.
- C. Facilitate laboratory studies for kidney function.
- D. Reassure the parents that this is a normal deviation.
Correct Answer: B
Rationale: This infant may have an imperforate anus, a condition that is an emergency, as the infant cannot pass stool. The nurse should quickly assess the baby's abdomen for distention and firmness and notify the physician or health-care provider. The other actions are not warranted.
The nurse assesses four newborns. Which of the following assessment findings would place a newborn at risk for developing physiologic jaundice?
- A. Mongolian spots
- B. Molding
- C. Cephalohematoma
- D. Telangiectatic nevi
Correct Answer: C
Rationale: Cephalohematomas can cause breakdown of red blood cells, leading to increased bilirubin levels and jaundice.