A nurse is assessing a newborn who has late-onset VKDB due to exclusive breastfeeding and inadequate oral vitamin K supplementation.
Which of the following findings should indicate a possible intracranial hemorrhage to the nurse?
Bulging fontanelle
Sunken eyes
Mottled skin
Flaring nostrils
The Correct Answer is A
The correct answer is choice A. Bulging fontanelle.
A bulging fontanelle is a sign of increased intracranial pressure, which can be caused by intracranial hemorrhage.
Late-onset VKDB is a condition that occurs in infants who have low levels of vitamin K, which is essential for blood clotting. Most cases of late-onset VKDB present with intracranial hemorrhage.
Choice B. Sunken eyes is wrong because it is a sign of dehydration, not intracranial hemorrhage.
Choice C. Mottled skin is wrong because it is a sign of poor circulation or shock, not intracranial hemorrhage.
Choice D. Flaring nostrils is wrong because it is a sign of respiratory distress, not intracranial hemorrhage.
Normal ranges for vitamin K plasma concentrations are 0.2 to 3.2 ng/mL for adults and 0.15 to 1.5 ng/mL for infants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. Hypersensitivity.Erythromycin eye ointment is an antibiotic that can cause allergic reactions in some newborns, such as irritation, redness, swelling, or cloudy eyes.
This is a potential adverse reaction to this medication that the nurse should monitor for.
Choice B. Glaucoma is wrong because glaucoma is a condition that causes increased pressure in the eye and can damage the optic nerve.
It is not caused by erythromycin eye ointment.
Choice C. Cataracts is wrong because cataracts are a condition that causes clouding of the lens of the eye and can impair vision.
It is not caused by erythromycin eye ointment.
Choice D. Strabismus is wrong because strabismus is a condition that causes misalignment of the eyes and can affect depth perception.
It is not caused by erythromycin eye ointment.
Erythromycin eye ointment is used to prevent ophthalmia neonatorum, which is an infection of the eye surface that affects newborns within the first month of life.It can be caused by bacteria such as chlamydia or gonorrhea that can enter the baby’s eyes during childbirth and cause permanent damage to the corneas.Erythromycin eye ointment can help prevent vision loss caused by these bacteria.
Correct Answer is B
Explanation
The correct answer is choice B.“I should bathe him before a feeding so he won’t spit up.” This statement indicates a need for further instruction because it is not advisable to bathe a newborn infant before a feeding, as this may cause hypoglycemia or cold stress.The mother should bathe the infant after a feeding or between feedings when the infant is alert and comfortable.
Choice A is wrong because it is correct to use a clean cloth and warm water to wash around the umbilical cord.This helps prevent infection and promotes drying of the cord stump.
Choice C is wrong because it is correct to avoid getting water in the infant’s ears or eyes.This helps prevent ear infections and eye irritation.
Choice D is wrong because it is correct to dry the infant thoroughly and dress him warmly after bathing.
This helps prevent heat loss
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