NCLEX-PN Review Question 1

A nurse is reviewing the record of a newborn infant in the nursery and notes that the physician has documented the presence of a cephalhematoma. Based on this documentation, the nurse expects to note which of the following on data collection of the infant?

1. Swelling of the soft tissues of the head and scalp

2. Edema resulting from bleeding below the periosteum of the cranium

3. A suture split greater than 1 cm

4. A hard, rigid immobile suture line

 

Answer:
2
Rationale:A cephalohematoma indicates edema resulting from bleeding below the periosteum of the cranium. It does not cross the suture line. It is most likely due to ruptured blood vessels from head trauma during birth. It develops within 24 to 48 hours after birth and may take 2 to 3 weeks to resolve. Option 1 identifies a caput succedaneum. Option 3 may indicate increased intracranial pressure. Option 4 may be associated with premature closure or craniosynostosis and should be investigated further.

Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Maternity/Postpartum

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