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
ANS: C
A cephalohematoma is caused by a collection of blood beneath the periosteum of the cranial bone. It does not cross the suture line.
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Regulation of intracranial pressure is explained by the Monro-Kellie doctrine. Based on this doctrine, under normal circumstances, if a patient's brain volume increases, what compensatory change does the nurse expect?
A) Reduction of cerebral blood volume B) Increased cerebrospinal fluid volume C) Increased cerebrospinal fluid production D) Elevation of systemic blood pressure
An infant born via cesarean section because of a breech presentation is diagnosed with bilateral congenital hip dysplasia. The primary nursing intervention directed toward this diagnosis is:
1. Assessing the infant frequently to determine abduction of the thighs 2. Maintaining the infant in the position of continuous abduction of both hips 3. Educating the parents about the importance of positioning the infant so that the head of the femurs are in alignment with the hip sockets 4. Providing pain management so that the infant is comfortable in the therapeutic position required
A client has experienced an adverse reaction to an immunization. The nurse has reported the event to the Vaccine Adverse Event Reporting System (VAERS). What response should the nurse expect from this group?
Standard Text: Select all that apply. 1. An officer from VAERS will contact the nurse by telephone for follow-up. 2. The VAERS office will contact the client for verification of the report. 3. The data will be added to other data about the vaccine. 4. Information from the report will be published in a central repository. 5. The nurse will be asked to report the event to the state board of nursing.
The nurse is caring for a client who suffers from anxiety. The client informs the nurse that he has been taking the herb kava. The nurse should be aware that kava carries the potential for which of the following?
A) Liver damage B) Renal failure C) Brain damage D) Cardiomyopathy