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 B

Explanation

The correct answer is choice B. Give the vaccine intramuscularly in the anterolateral thigh.

This is because the anterolateral thigh is the recommended site for intramuscular injections in infants less than 12 months of age.

It has a large muscle mass and minimal risk of injury to nerves or blood vessels.

Choice A is wrong because informed consent is not required for routine immunizations, unless the parent or guardian requests more information or declines the vaccine.

Choice C is wrong because hepatitis B immune globulin (HBIG) is only indicated for newborns whose mothers are hepatitis B surface antigen positive (HBsAg+), as they have a high risk of acquiring the infection from their mothers.

Choice D is wrong because there is no need to delay giving the vaccine until after breastfeeding is established.

Breastfeeding does not interfere with the vaccine’s effectiveness or safety, and it does not increase the risk of adverse reactions.

A. Ask the mother if she has any allergies to antibiotics B. Check if there is any cross-sensitivity between erythromycin and penicillin C. Apply a small amount of ointment on the skin to test for allergic reaction D. Administer an antihistamine to prevent anaphylaxis

Correct Answer is B

Explanation

The correct answer is choice B. Check if there is any cross-sensitivity between erythromycin and penicillin.Erythromycin is a macrolide antibiotic that can be used to treat bacterial eye infections in newborns and adults.

Penicillin is a beta-lactam antibiotic that can cause allergic reactions in some people.

Cross-sensitivity means that a person who is allergic to one type of antibiotic may also be allergic to another type of antibiotic that has a similar structure or mechanism of action.Erythromycin and penicillin have different structures and mechanisms of action, but there is still a small chance of cross-sensitivity between them.

Therefore, the nurse should check if the newborn has any history of allergic reaction to penicillin before applying the erythromycin eye ointment.

Choice A is wrong because asking the mother if she has any allergies to antibiotics is not enough to determine if the newborn is at risk of an allergic reaction to erythromycin.

The newborn may have inherited or developed an allergy to penicillin or erythromycin that the mother does not have.

Choice C is wrong because applying a small amount of ointment on the skin to test for allergic reaction is not a reliable method to diagnose an allergy.Skin testing can cause false positive or false negative results, and it may also trigger a severe allergic reaction in some cases.

Choice D is wrong because administering an antihistamine to prevent anaphylaxis is not appropriate for a newborn who has not been exposed to the allergen yet.

An antihistamine is a medication that blocks the effects of histamine, a chemical that causes allergic symptoms.

Anaphylaxis is a life-threatening allergic reaction that involves multiple organ systems and requires immediate medical attention.An antihistamine cannot prevent anaphylaxis, and it may also cause side effects such as drowsiness, dry mouth, or low blood pressure in a newborn.

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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

A nurse is preparing to administer hepatitis B vaccine to a newborn whose mother is hepatitis B surface antigen negative (HBsAg-). Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is administering erythromycin eye ointment to a newborn who has a history of allergic reaction to penicillin. What should the nurse do before applying the ointment?

Correct Answer is B

Explanation

A nurse is reviewing laboratory results for a newborn who received vitamin K injection at birth. Which of the following coagulation factors should be activated by vitamin K?

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A nurse is caring for a preterm newborn who has hypoglycemia due to inadequate gluconeogenesis. The nurse should understand that this condition occurs because preterm newborns have limited stores of which of the following substances?

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?