A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The newborn's mother asks about the swollen area on her son's head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse?

Correct Answer: C

Rationale: The correct answer is C: "This is a cephalhematoma, which can occur spontaneously." 1. Cephalhematoma is a subperiosteal hemorrhage that does not cross suture lines and is due to trauma during delivery. 2. Caput succedaneum (choice B) occurs due to pressure during labor and resolves within a few days. 3. Mongolian spots (choice A) are benign bluish-grey birthmarks commonly found in newborns and are not related to head swelling. 4. Erythema toxicum (choice D) is a common rash in newborns, not related to head swelling. In summary, the correct choice is C because it accurately describes the condition observed in the newborn after vacuum-assisted delivery.

Correct Answer: C

Rationale: The correct answer is C: Voids 6 or more times a day. Adequate breast milk intake is indicated by frequent urination (6 or more times/day) in infants. This shows the infant is hydrated and receiving enough milk. The other choices are incorrect because A) pacifier use doesn't indicate milk supply, B) hard stools can be a sign of dehydration or other issues, and D) feeding every 4 hours is a general guideline but not a definitive indicator of milk supply.

Correct Answer: A

Rationale: The correct answer is A: Check the fetal heart rate. This is the first action to assess the well-being of the fetus after the reported fluid gush, ensuring fetal safety. Checking fetal heart rate is crucial in determining fetal distress. Assessing for meconium staining (B) is important but comes after confirming fetal well-being. Performing a sterile vaginal examination (C) may introduce infection and should be avoided without proper indications. Notifying the healthcare provider (D) is necessary but should follow initial assessment of fetal status.

Correct Answer: B

Rationale: Rationale for Correct Answer (B): Limiting visitors and monitoring closely for signs of infection in a newborn in the NICU is crucial because newborns are highly vulnerable to infections. By restricting visitors, the risk of introducing pathogens is reduced. Close monitoring allows for early detection of any signs of infection, enabling prompt intervention to prevent complications. Summary of Other Choices: A: While maintaining strict hand hygiene is important, it alone is not sufficient to reduce the risk of infection in a newborn in the NICU. C: Proper sterilization of equipment is essential but may not directly address the risk of infection transmission from visitors or other sources. D: Administering prophylactic antibiotics is not recommended as a routine measure due to the potential for antibiotic resistance and adverse effects in newborns. Monitoring and prevention are preferred over indiscriminate antibiotic use.

Correct Answer: B

Rationale: The correct answer is B because joining a support group can provide emotional support and reduce feelings of isolation, which are key factors in preventing postpartum depression. Printed educational material (A) may not offer personalized support. Assessing for risk factors (C) is important but alone may not prevent depression. Administering antidepressants (D) is a treatment, not a prevention strategy.