Which is defined as a vaguely outlined area of edematous tissue situated over the portion of the scalp that presents in a vertex delivery?

Correct Answer: A

Rationale: Caput succedaneum is the vaguely outlined area of edematous tissue situated over the portion of the scalp that presents in a vertex delivery. It is often caused by pressure from the vaginal wall during labor. This condition does not involve the calvarial bone and typically resolves on its own within a few days after birth. Hydrocephalus refers to the abnormal accumulation of cerebrospinal fluid within the brain, which can result in an enlarged head circumference. Cephalhematoma is a collection of blood between the periosteum and the skull bone, usually occurring after birth trauma. Subdural hematoma is bleeding between the dura mater and the arachnoid mater surrounding the brain and is typically seen in traumatic head injuries.

Correct Answer: D

Rationale: During the acute phase of treatment with IV calcium gluconate for hypocalcemia in a newborn, it is essential to closely monitor the newborn's level of consciousness. Hypocalcemia can lead to central nervous system changes, such as irritability, jitteriness, and seizures. By awakening the newborn periodically to assess their level of consciousness, the nurse can promptly identify any signs of worsening central nervous system involvement and take appropriate action. This intervention ensures timely detection of any neurological complications and allows for timely intervention to prevent serious consequences. The other options do not address the importance of monitoring for central nervous system changes during the acute phase of treatment for hypocalcemia.

Correct Answer: C

Rationale: Encouraging the breastfeeding mother to adhere to a low-phenylalanine diet is an important nursing consideration in the care of the newborn with PKU. Phenylketonuria (PKU) is an inborn error of metabolism in which the body cannot metabolize phenylalanine properly. If a newborn with PKU consumes formula or breast milk that contains high levels of phenylalanine, it can lead to severe intellectual disability and other health complications. By encouraging the breastfeeding mother to follow a low-phenylalanine diet, the newborn's exposure to phenylalanine can be minimized, helping to prevent the negative effects of PKU.

Correct Answer: B

Rationale: Using a simple magic trick with gauze to engage a 5-year-old child during a dressing change is a way to establish rapport. This approach can help build trust and reduce anxiety by making the procedure more engaging and less intimidating for the child. By creating a positive interaction through a fun activity, the nurse can promote cooperation and make the dressing change a smoother experience for the child. Overall, the use of a magic trick in this context is appropriate and beneficial for enhancing the child's cooperation and comfort.

Correct Answer: C

Rationale: Petechiae are small, pinpoint, red or purple spots on the skin caused by bleeding into the skin. In dark-skinned individuals, it can be challenging to visualize petechiae due to the pigmentation of the skin. However, one of the best places to observe for the presence of petechiae in dark-skinned individuals is the oral mucosa, specifically the inner lining of the mouth. The oral mucosa is usually lighter in color compared to the skin, making it easier to identify petechiae in this area. Palms and soles may also be a good place to observe for petechiae, but the oral mucosa is typically the preferred site for examination in dark-skinned individuals.