A nurse palpates an infant’s anterior fontanelle and notes that it feels soft and flat when lying down, but slightly elevated when sitting up or crying.

What should be included in documentation?

Normal finding

Dehydration

Increased intracranial pressure

Infection

Answer and Explanation

The Correct Answer is A

Normal finding.

The anterior fontanelle is the soft spot on the top of an infant’s head that allows for brain growth and skull expansion.

It normally feels soft and flat when the infant is lying down, and may bulge slightly when the infant is sitting up or crying due to increased blood flow and pressure.

This is not a sign of any problem and should be documented as a normal finding.

Dehydration is wrong because dehydration would cause the fontanelle to feel sunken or depressed, not elevated. Dehydration can also cause other signs such as dry mouth, decreased urine output, and lethargy.

Increased intracranial pressure is wrong because increased intracranial pressure would cause the fontanelle to feel tense or bulging at all times, not only when sitting up or crying. Increased intracranial pressure can also cause other signs such as vomiting, irritability, seizures, and altered level of consciousness.

Infection is wrong because infection would cause the fontanelle to feel warm or tender, not elevated. Infection can also cause other signs such as fever, rash, poor feeding, and fussiness.

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Correct Answer is B

Explanation

Cover the newborn’s eyes with eye shields or patches.This is because phototherapy can cause eye damage and irritation to the newborn, so the eyes should be protected while the lights are on.

Some possible explanations for the other choices are:

• Choice A is wrong because applying sunscreen to the newborn’s skin before placing under the lights can interfere with the effectiveness of phototherapy and increase the risk of skin irritation and infection.

• Choice C is wrong because turning off the phototherapy lights during feedings can reduce the exposure time and delay the clearance of bilirubin from the newborn’s blood.

• Choice D is wrong because keeping the newborn fully clothed to prevent heat loss can also interfere with the effectiveness of phototherapy and increase the risk of overheating and dehydration.

Normal ranges for bilirubin levels in newborns vary depending on the age, gestational age, and risk factors of the newborn.Generally, a total serum bilirubin level of less than 12 mg/dL (205 micromol/L) is considered normal for term newborns in the first week of life.Phototherapy is usually indicated when the total serum bilirubin level exceeds 15 mg/dL (257 micromol/L) for term newborns or 10 mg/dL (171 micromol/L) for preterm newborns.

A. Thin and transparent skin B. Well-developed breast buds C. Creases on the bottom of feet D. Developed labia.

Correct Answer is A

Explanation

Thin and transparent skin is a sign of prematurity in newborns.The New Ballard Scale is a scale that estimates the gestational age of a newborn infant based on physical and neuromuscular characteristics.

The other choices are signs of maturity or postmaturity in newborns:

• Choice B: Well-developed breastbuds indicate a gestational age of 38 to 44 weeks.

• Choice C: Creases on the bottom of feet indicate a gestational age of 32 to 44 weeks.

• Choice D: Developed labia indicate a gestational age of 40 to 44 weeks.

The normal range for gestational age is 37 to 42 weeks.Premature infants are those born before 37 weeks, and postmature infants are those born after 42 weeks.

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A nurse palpates an infant’s anterior fontanelle and notes that it feels soft and flat when lying down, but slightly elevated when sitting up or crying. What should be included in documentation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn who has hyperbilirubinemia and is receiving phototherapy. Which of the following interventions should the nurse implement?

Correct Answer is B

Explanation

A nurse is assessing a newborn's gestational age using the New Ballard Scale. Which of the following signs would indicate prematurity?

Correct Answer is A

Explanation

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A nurse palpates an infant’s anterior fontanelle and notes that it feels soft and flat when lying down, but slightly elevated when sitting up or crying.

What should be included in documentation?