Nokea
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.
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What should nursing care of an infant with oral candidiasis (thrush) include?
- A. Avoid use of a pacifier.
- B. Continue medication for the prescribed number of days.
- C. Remove the characteristic white patches with a soft cloth.
- D. Apply medication to the oral mucosa, being careful that none is ingested.
Correct Answer: B
Rationale: The medication must be continued for the prescribed number of days. To prevent relapse, therapy should continue for at least 2 days after the lesions disappear. Pacifiers can be used. The pacifier should be replaced with a new one or boiled for 20 minutes once daily. One of the characteristics of thrush is that the white patches cannot be removed. The medication is applied to the oral mucosa and then swallowed to treat Candida albicans infection in the gastrointestinal tract.
Which intervention may decrease the incidence of physiologic jaundice in a healthy full-term infant?
- A. Institute early and frequent feedings.
- B. Bathe newborn when the axillary temperature is 36.3 C (97.5 F).
- C. Place the newborns crib near a window for exposure to sunlight.
- D. Suggest that the mother initiate breastfeeding when the danger of jaundice has passed.
Correct Answer: A
Rationale: Physiologic jaundice is caused by the immature hepatic function of the newborns liver coupled with the increased load from red blood cell hemolysis. The excess bilirubin from the destroyed red blood cells cannot be excreted from the body. Feeding stimulates peristalsis and produces more rapid passage of meconium. Bathing does not affect physiologic jaundice. Placing the newborns crib near a window for exposure to sunlight is not a treatment of physiologic jaundice. Colostrum is a natural cathartic that facilitates meconium excavation.
A mother brings her 6-week-old infant in with complaints of poor feeding, lethargy, fever, irritability, and a vesicular rash. What does the nurse suspect?
- A. Impetigo
- B. Candidiasis
- C. Neonatal herpes
- D. Congenital syphilis
Correct Answer: C
Rationale: Neonatal herpes is one of the most serious viral infections in newborns, with a mortality rate of up to 60% in infants with disseminated disease. Bullous impetigo is an infectious superficial skin condition most often caused by Staphylococcus aureus infection. It is characterized by bullous vesicular lesions on previously untraumatized skin. Candidiasis is characterized by white adherent patches on the tongue, palate, and inner aspects of the cheeks. Congenital syphilis has multisystem manifestations, including hepatosplenomegaly, lymphadenopathy, hemolytic anemia, and thrombocytopenia.
The nurse is caring for a newborn with Erb palsy. The nurse understands that which reflex is absent with this condition?
- A. Root reflex
- B. Suck reflex
- C. Grasp reflex
- D. Moro reflex
Correct Answer: D
Rationale: Erb palsy (Erb-Duchenne paralysis) is caused by damage to the upper plexus and usually results from stretching or pulling away of the shoulder from the head. The Moro reflex is absent in a newborn with Erb palsy. The root and suck reflex are not affected. A grasp reflex is present in newborns because the finger and wrist movements remain normal.
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.