Edward, a newborn delivered at 41 weeks' gestation, weighs 10 lb 4 oz. Vaginal delivery for this G1P1 mother was assisted with forceps. The nurse is completing her assessment and notes a sharply demarcated swelling over the parietal bones. The occipital and frontal skull bones are not affected. The neck does not appear edematous and is soft to the touch with full mobility. The infant is awake and active and has been breast-feeding well. What is the most probable cause of the swelling?

Correct Answer: A

Rationale: The correct answer is A: cephalohematoma. Cephalohematoma is a subperiosteal collection of blood that occurs due to trauma during delivery, such as with forceps assistance. The swelling is sharply demarcated because it is bound by suture lines of the skull bones. In this case, the parietal bones are affected, while the other skull bones are not involved. The absence of edema in the neck and the infant's good activity and feeding suggest no significant underlying issues. Summary: B: Subgaleal hemorrhage involves bleeding into the potential space between the periosteum and the skull, resulting in diffuse swelling extending beyond suture lines. C: Caput succedaneum is soft tissue swelling that crosses suture lines and involves the scalp, not just the parietal bones. D: Skull fracture would present with additional signs such as crepitus, misshapen skull, or neurological deficits, which are not mentioned

Correct Answer: B

Rationale: The correct answer is B because artificial surfactant improves the ability of the infant's lungs to exchange oxygen and carbon dioxide. Surfactant reduces surface tension in the alveoli, preventing collapse and helping with gas exchange. This explanation directly relates to the purpose of surfactant therapy in treating RDS. Choices A, C, and D are incorrect because they do not accurately describe the mechanism or purpose of surfactant therapy. Choice A is incorrect as surfactant does not affect sedation needs, choice C is incorrect as surfactant is not used to address tachycardia, and choice D is incorrect as surfactant is not used to treat respiratory tract infections.

Correct Answer: C

Rationale: The correct answer is C: The newborn is experiencing respiratory distress. Gasping respirations, low heart rate, cyanotic skin, and poor muscle tone are indicative of respiratory distress in a newborn. Gasping is an abnormal breathing pattern seen in severe respiratory distress. A low heart rate is a compensatory response to decreased oxygen levels. Cyanotic skin color indicates poor oxygenation. Poor muscle tone can be a sign of inadequate oxygen delivery to tissues. Explanation for other choices: A: The newborn may be hypothermic due to poor temperature regulation, but the primary concern in this scenario is respiratory distress. B: Being full term does not directly explain the newborn's clinical presentation, so it is not a likely cause. D: Anemia could contribute to poor oxygen delivery, but the clinical presentation suggests a more acute issue related to respiratory distress.

Correct Answer: D

Rationale: The correct answer is D because discharge teaching should start as early as possible and continue throughout the admission to ensure the family receives adequate education and support. Starting early allows for more time to address any concerns, teach necessary skills, and build confidence in caring for the premature infant. This approach promotes better outcomes for both the infant and the family. Choice A is incorrect because waiting for the infant to meet specific goals may delay essential education and support for the family. Choice B is incorrect as it focuses on a specific medical intervention rather than comprehensive teaching. Choice C is incorrect because interest alone may not indicate readiness or understanding of the care required for a premature infant.

Correct Answer: C

Rationale: The correct answer is C because the mother was trained on NG tube replacement. This knowledge ensures proper technique and reduces the risk of injury. Driving to the ER or calling 911 may waste time, and feeding by mouth without the NG tube is not safe. Replacing the NG tube at home is the most efficient and appropriate course of action in this scenario.