NR-327 Maternal-Child Nursing - Set 5 - Part 3

Correct Answer: Cephalhematoma from bleeding under the periosteum

Blood collecting between the skull bone and its covering membrane cannot cross a suture line, so the swelling stays on one bone, shows up hours later and resolves over weeks. Option a is incorrect because scalp edema sits above the bone and spreads freely across suture lines. It is present right at birth, pits under a finger and fades within a few days. Option c is incorrect because overlapping skull bones change the head shape without producing a fluid filled lump. Molding is visible immediately and rounds out on its own in a couple of days. Option d is incorrect because bleeding into that potential space spreads widely, shifts with position and can cause shock from blood loss. The boundary described here rules out such a diffuse collection.

Correct Answer: Falling glucose with increased oxygen consumption

Burning brown fat to make heat consumes glucose and oxygen quickly, so a chilled preterm infant slides into hypoglycemia and hypoxia, and the resulting acidosis further suppresses surfactant production. Option a is incorrect because heat production draws down the sugar supply instead of raising it. Oxygen demand climbs at the same time, which is the opposite of what this option claims. Option b is incorrect because a cold newborn speeds metabolism rather than slowing it. Non shivering thermogenesis is expensive work, and the infant burns stored calories fast trying to stay warm. Option c is incorrect because chilling and the acidosis that follows shut surfactant production down. Alveoli then collapse more readily, so breathing becomes harder for this infant rather than easier.

Correct Answer: Radiation to a nearby cooler surface

Radiation transfers heat to a colder object that sits near the infant without touching, so a cold windowpane and outside wall steadily pull warmth from the bassinet. Moving it inward corrects this. Option a is incorrect because conduction requires direct contact, such as a chilled mattress or a cold stethoscope pressed to the chest. Nothing in this bassinet is touching the infant and stealing warmth. Option c is incorrect because convection needs air in motion, from a vent, a doorway, or an open porthole. The scenario describes a still room where the cold surface itself is the problem. Option d is incorrect because evaporative loss depends on wetness, seen after a bath or with amniotic fluid still on the skin. This infant is dry, so vapor is not carrying heat away.

Correct Answer: A brachial plexus injury of the upper roots

Stretching of the upper nerve roots leaves the arm adducted, internally rotated and pronated in the waiter tip position, with the Moro absent on that side while the grasp stays intact. Option a is incorrect because a broken collarbone announces itself with crepitus, a palpable lump and crying when the arm is moved. The limb still moves, unlike the flaccid arm described here. Option b is incorrect because shoulder dislocation is rare in newborns and would show obvious joint deformity with pain on any movement. Nerve stretching, not joint displacement, explains this classic arm posture. Option c is incorrect because fracture of the upper arm bone produces swelling, angulation and marked tenderness over the shaft. Nothing in this examination points to bony injury below the shoulder.

Correct Answer: Remove the shields and inspect the eyes

Shields come off once the lights are switched off, which lets the mother make eye contact with her infant and lets the nurse check for corneal irritation or drainage. Option b is incorrect because keeping the eyes covered away from the lights blocks the visual contact that supports attachment. Shields serve a purpose only while the blue light is shining. Option c is incorrect because a blanket over the face is not an opaque shield and slips easily. Loose cloth also poses a suffocation hazard and never substitutes for fitted eye protection. Option d is incorrect because clothing the newborn works against the whole plan of maximum skin exposure. The infant returns under the lights in a diaper, so full dressing wastes treatment time.

Correct Answer: Blue discoloration of the lips and tongue

Central cyanosis of the lips, tongue, and mucous membranes always means hypoxemia from a cardiac or respiratory cause. The nurse assesses airway and breathing, applies pulse oximetry, and notifies the provider. Option a is incorrect because congenital dermal melanocytosis is harmless pigment common in infants with darker skin. The nurse documents its size and location so the marks are not later mistaken for bruising. Option b is incorrect because lanugo covers the shoulders, back, and forehead of many newborns and simply sheds over the following weeks. Its presence describes maturity, not illness, and calls for no intervention. Option d is incorrect because vernix caseosa protects fetal skin and is heaviest in the folds at term. Leaving it to absorb supports the skin barrier, so its presence is reassuring rather than alarming.

Correct Answer: An axillary temperature of ninety six degrees Fahrenheit

An axillary reading in the ninety six degree range falls under the expected floor and signals cold stress, which drives oxygen and glucose consumption upward. The nurse warms the infant and checks a glucose level. Option b is incorrect because a crying newborn commonly pushes the heart rate toward one hundred eighty. Rechecking once the infant settles usually shows a rate back inside the resting range with no other change. Option c is incorrect because breathing in the fifties sits comfortably within the expected thirty to sixty range. Newborn respirations are irregular and abdominal, and this value carries no sign of distress. Option d is incorrect because that temperature falls squarely inside the expected axillary window for a term infant. Routine care continues, with rechecks every few hours once the newborn has stayed stable.

Correct Answer: Increase feeding frequency and monitor intake and output

Insensible losses through the skin and loose stools rise under lights, so more frequent feeding with careful intake and output tracking restores hydration and keeps bilirubin moving out through the gut. Option a is incorrect because halting treatment while the bilirubin is still high risks a rebound rise. Dehydration is corrected by feeding the infant, not by abandoning the light therapy. Option b is incorrect because plain water carries no calories and cuts down stool volume. Less stooling means more bilirubin gets reabsorbed from the intestine, so the level climbs instead of falling. Option c is incorrect because another weight check gathers data without fixing anything. The record already shows falling output and weight loss, and delaying fluid replacement lets dehydration deepen.

Correct Answer: The clot in the leg after surgery

A past deep vein thrombosis places the client in the category where estrogen carries an unacceptable risk, because the estrogen component raises clotting risk further, so a progestin only method or an intrauterine device is offered. Option a is incorrect because allergic rhinitis has no bearing on clotting or vascular tone. Antihistamines and estrogen do not interact in a way that would change eligibility for this method. Option c is incorrect because iron deficiency anemia is not a barrier to estrogen. Combined pills lighten menstrual flow, so many clinicians see the anemia as a reason to favor this method rather than avoid it. Option d is incorrect because painful periods are a recognized non contraceptive benefit rather than a barrier. Suppressing ovulation lowers prostaglandin release, so cramping usually improves once the client has been on the pill for a few cycles.

Correct Answer: Bright bleeding that soaks a quarter sized area

Blood loss beyond a few spots, enough to spread across a quarter sized area of the diaper, calls for gentle pressure and provider notification. Newborns have a small blood volume and tolerate very little loss. Option a is incorrect because a yellowish white layer over the glans on the second day is granulation tissue forming as the site heals. Wiping it away disturbs the surface, so it stays untouched. Option b is incorrect because petroleum gauze is exactly what a Gomco site needs for the first day or two. The jelly keeps the diaper from sticking to raw tissue and pulling the healing skin. Option d is incorrect because a newborn who settles with swaddling and sucrose is showing ordinary discomfort that comfort measures manage well. Persistent inconsolable crying would raise concern, and that is not the case here.