Question

After a difficult delivery, a newborn develops a large cephalohematoma. The nurse will monitor this infant for: A. infection B. brain damage C. hyperbilirubinemia D. congestive heart failure

Short answer

C. hyperbilirubinemia

Step-by-step solution

Understanding Cephalohematoma

Cephalohematoma is a condition whereby blood accumulates between the skull and the periosteum due to ruptured blood vessels during delivery. It is common in newborns and does not pose an immediate threat to brain tissue as the bleed is outside the brain. A nurse would monitor this infant for complications that could arise from the condition.

Identifying Complications Associated with Cephalohematoma

One of the complications that can arise from cephalohematoma is hyperbilirubinemia. This condition develops when the red blood cells within the hematoma breakdown and are reabsorbed into the circulation, leading to increased levels of bilirubin in the infant's blood.

Eliminating Other Options

Infection is typically a risk with any skin break or injury but is less directly connected to cephalohematoma. Brain damage is unlikely since the bleed is outside the brain, and congestive heart failure is not related to the condition of cephalohematoma.

Choosing the Correct Answer

The nurse will monitor the infant for hyperbilirubinemia since it is a direct complication associated with the breakdown of red blood cells from the cephalohematoma being reabsorbed into the infant's circulation.

Key concepts

Hyperbilirubinemia

When a newborn experiences a condition such as cephalohematoma, there's an increased risk for another significant concern called hyperbilirubinemia. This occurs when there is an elevated level of bilirubin in the blood, a yellowish substance that's produced by the breakdown of red blood cells.

In a healthy newborn, the liver processes bilirubin, which is then excreted through stool. However, if there's an excessive breakdown of red blood cells, as can happen with the reabsorption of a cephalohematoma, the infant's still-maturing liver may be overwhelmed, leading to jaundice—evidenced by yellowing of the skin and eyes.

Signs and Risks

Nurses and parents should watch for signs of jaundice in newborns within the first few days post-birth. If left unchecked, severe hyperbilirubinemia may lead to permanent brain damage, a condition known as kernicterus. Therefore, monitoring bilirubin levels and early treatment, which might include phototherapy or blood transfusions, is critical. Nursing care involves educating parents about potential signs and keeping close tabs on at-risk newborns.

Newborn Complications

Cephalohematoma in newborns can open the door to a variety of other complications besides hyperbilirubinemia.

While a cephalohematoma itself is generally not a threat to the infant’s brain, it does indicate that the birth was likely difficult. Newborns who have experienced such traumas may exhibit other complications such as bruising, injury to skeletal muscles, or even fractures.

Symptom Surveillance

Awareness of these risks necessitates vigilant monitoring for symptoms such as excessive crying, which may signal pain; reluctance to move an affected limb; or difficulties with feeding. Early detection of these issues is essential in guiding decisions about further medical evaluations or interventions to prevent long-term sequelae.

Nursing Care for Cephalohematoma

The role of a nurse in managing cephalohematoma extends beyond merely monitoring for hyperbilirubinemia. Nursing care includes a comprehensive approach that ensures the comfort and safety of the newborn while supporting the family.

Evaluation and Support

Careful evaluation of the infant's head circumference and overlying skin is vital to track the progression of the cephalohematoma. Nurses also provide pain management and educate parents about what to expect as the cephalohematoma resolves, which can take a few weeks to months.

In the educational aspect, nurses explain normal healing processes, signs of complications, and when to seek further medical advice. The emotional support for concerned family members is another important component of the care plan.

NCLEX-RN Exam Preparation

Preparation for the NCLEX-RN exam requires a deep understanding of various newborn complications, including cephalohematoma and its potential secondary issues such as hyperbilirubinemia. This foundational knowledge assists in making critical decisions regarding patient care in the exam scenarios.

Prospective nurses must familiarize themselves with the pathophysiology, signs, and symptoms of conditions, as well as appropriate nursing interventions.

Study Strategies

Effective study strategies include practicing with question banks that simulate the exam, participating in study groups, and utilizing NCLEX preparation courses. The ability to prioritize care based on patient needs, a critical aspect of the NCLEX-RN, often comes down to proficient comprehension of the material, active learning methods, and consistent study habits.