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 C

Explanation

The newborn had some problems at birth but is now in excellent condition.

The Apgar score is a method of assessing the health of a newborn on a scale of 0 to 10 based on five criteria: appearance, pulse, grimace, activity, and respiration.

A score of 7 to 10 indicates that the newborn is in good condition and does not need any special care.

A score of 4 to 6 indicates that the newborn has some problems and may need some assistance.

A score of 0 to 3 indicates that the newborn is in serious trouble and needs immediate medical attention.

Choice A is wrong because a score of 8 at one minute after birth does not indicate a difficult transition.

It means that the newborn had only minor problems and was in good condition.

Choice B is wrong because a score of 10 at five minutes after birth does not indicate an improvement from a score of 8.

It means that the newborn had no problems and was in excellent condition.

Choice D is wrong because a score of 10 at five minutes after birth does not indicate a deterioration from a score of 8.

It means that the newborn had no problems and was in excellent condition.

Normal ranges for the Apgar score are:

• At one minute after birth: 7 to 10

• At five minutes after birth: 8 to 10

A. Sunken fontanelles B. Bulging fontanelles C. Diamond-shaped anterior fontanelle D. Triangular posterior fontanelle.

Correct Answer is B

Explanation

Bulging fontanelles.Bulging fontanelles can be a sign of increased intracranial pressure or intracranial and extracranial tumors.This is a potential problem for the newborn’s brain and health and should be evaluated by imaging studies.

Choice A is wrong because sunken fontanelles are usually a sign of dehydration, which is not a problem with the fontanelles themselves, but with the fluid balance of the newborn.

Choice C is wrong because a diamond-shaped anterior fontanelle is normal for a newborn.The anterior fontanelle is the largest and most important for clinical evaluation.It has an average size of 2.1 cm and a median time of closure of 13.8 months.

Choice D is wrong because a triangular posterior fontanelle is also normal for a newborn.The posterior fontanelle is smaller than the anterior one and normally closes by 8 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 an Apgar score of 8 at one minute after birth and an Apgar score of 10 at five minutes after birth. Which statement best describes this newborn’s condition?

Correct Answer is C

Explanation

A nurse is performing a head-to-toe assessment of a newborn. What finding should alert the nurse to a potential problem with the newborn’s fontanelles?

Correct Answer is B

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?