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

Answer and Explanation

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.

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Correct Answer is C

Explanation

The correct answer is choice C. A temperature of 36°C (96.8°F) is below the normal range for a newborn, which is 36.5°C to 37.5°C (97.7°F to 99.5°F).

A low temperature can indicate hypothermia, infection, or hypoglycemia, and should be reported to the provider.

Choice A is wrong because a heart rate of 140/min is within the normal range for a newborn, which is 120 to 160/min.

Choice B is wrong because a respiratory rate of 50/min is within the normal range for a newborn, which is 30 to 60/min.

Choice D is wrong because a blood pressure of 60/40 mm Hg is within the normal range for a newborn, which is 50 to 75/30 to 45 mm Hg.

A. Factor II B. Factor V C. Factor VIII D. Factor XI

Correct Answer is A

Explanation

The correct answer is choice A.Factor II, also known as prothrombin, is one of the coagulation factors that are activated by vitamin K.Vitamin K is a cofactor for the carboxylation of specific glutamic acid groups in coagulation factors II, VII, IX, and X.

This process is essential for the activation of these factors in the coagulation cascade.

Choice B is wrong because factor V is not a vitamin K-dependent coagulation factor.

Factor V is activated by thrombin and acts as a cofactor for factor Xa in the conversion of prothrombin to thrombin.

Choice C is wrong because factor VIII is not a vitamin K-dependent coagulation factor.

Factor VIII is activated by thrombin and acts as a cofactor for factor IXa in the activation of factor X.

Choice D is wrong because factor XI is not a vitamin K-dependent coagulation factor.

Factor XI is activated by factor XIIa and activates factor IX in the intrinsic pathway of coagulation.

Normal ranges for coagulation factors are:

• Factor II: 70-120% of normal activity

• Factor V: 50-150% of normal activity

• Factor VIII: 50-150% of normal activity

• Factor IX: 50-150% of normal activity

• Factor X: 70-140% of normal activity

• Factor XI: 70-150% of normal activity

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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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?

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?