The nurse is conducting a body system assessment of the newborn. ...

[natalie2426]

The nurse is conducting a body system assessment of the newborn. Which are abnormal findings that the nurse should report? (Select all that apply.)
 
  a. Low-set ears
  b. Yellow sclera
  c. A doll's eye sign
  d. Edema of the eyelids
  e. Absence of the grasp reflex

Question 2

The postpartum nurse is providing care to a woman 2 hours after birth and to her newborn. On review of the newborn's chart, the nurse sees a notation of caput succedaneum. What will the nurse expect to find in the mother's chart?
 
  a. Racenon-white
  b. A longer than usual labor
  c. Administration of an epidural
  d. Delivery by cesarean section

[Eunice618]

Answer to Question 1

ANS: A, B, E
Low-set ears may indicate chromosomal abnormalities. The sclera should be white or bluish white. A yellow color indicates jaundice. Absence of reflexes may indicate a serious neurologic problem. The doll's eye sign is a normal finding in the newborn; when the head is turned quickly to one side, the eyes move toward the other side. Edema of the eyelids and subconjunctival hemorrhages (reddened areas of the sclera) result from pressure on the head during birth, which causes capillary rupture in the sclera.

Answer to Question 2

ANS: B
A caput succedaneum is an area of localized edema that appears over the vertex of the newborn's head as a result of pressure against the mother's cervix during labor. The pressure interferes with blood flow from the area, causing localized edema at birth. The edematous area crosses suture lines, is soft, and varies in size. The longer the labor, the more pronounced the caput. Mongolian spots are associated with infants born to non-white parents. An epidural may be a contributing factor to a prolonged labor, but it is the pressure of the head against the cervix that gives rise to the caput. If labor is prolonged without descent of the head, a cesarean section may follow but is not the cause of the caput.