Nokea
While inspecting a newborn's head, the nurse identifies a swelling of the scalp that does not cross the suture line. How would the nurse refer to this finding when documenting?
- A. Molding
- B. Caput succedaneum
- C. Cephalohematoma
- D. Enlarged fontanelle
Correct Answer: C
Rationale: A cephalohematoma is caused by a collection of blood beneath the periosteum of the cranial bone and does not cross the suture line.
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What does the nurse explain this transitory skin discoloration is called?
- A. Epstein's pearls
- B. Milia
- C. Stork bites
- D. Mongolian spots
Correct Answer: D
Rationale: Bluish skin discoloration over the sacral area of a newborn is a transitory condition called Mongolian spots.
What information will the nurse provide when educating this patient on alendronate (Fosamax)?
- A. Drink 8 oz. of water following dosage.
- B. Lay down for 30 minutes after taking.
- C. This medication has no known side effects.
- D. Avoid weight-bearing exercises.
Correct Answer: A
Rationale: Alendronate (Fosamax) may cause esophageal and gastric irritation. The patient should drink 8 ounces of plain water and sit upright for 30 minutes after taking the drug and before eating. Weight-bearing exercises are advisable, and high-impact exercises should be avoided.
What does the nurse explain as the cause?
- A. Premature stimulation of the ovarian hormones by the pituitary system
- B. Cessation of female sex hormones transferred in utero from mother to infant
- C. The increased amount of circulating blood from the mother throughout pregnancy
- D. Trauma to the genitalia during the birth process
Correct Answer: B
Rationale: Blood-tinged mucus discharged from the vagina is caused by hormonal withdrawal from the mother at birth.
What will the nurse expect the stool color to be 2 days after birth?
- A. Yellow
- B. Brown
- C. Greenish brown
- D. Black and tarry
Correct Answer: A
Rationale: The stool of a breastfed infant is bright yellow, soft, and pasty by 2 days after birth.
Which assessment of the newborn should be reported?
- A. Head circumference is 5 cm greater than the chest circumference.
- B. Hands and feet are warm with a blue color.
- C. Temperature is 36.6?°C (97.8?°F).
- D. Head has a longer than normal shape to it.
Correct Answer: A
Rationale: The circumference of the head should be less than 2 cm greater than that of the chest, and a 5 cm difference should be reported.