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. Document this as a normal finding.According to the American Academy of Family Physicians, bleeding from the dorsal slit after circumcision using a Gomco clamp is usually minimal and will stop once the clamp is in place.

Therefore, a small amount of blood on the diaper 12 hours after the procedure is not a cause for concern and does not require any intervention.

Choice A is wrong because applying gentle pressure to stop bleeding is not necessary and may cause more trauma to the wound.

Choice B is wrong because changing the diaper more frequently may also disturb the healing process and increase the risk of infection.Choice D is wrong because notifying the physician is not indicated unless there is excessive or persistent bleeding, signs of infection, or other complications.

A. Pancreatitis B. Lactic acidosis C. Hypothyroidism D. Nephrotoxicity

Correct Answer is B

Explanation

The correct answer is choice B. Lactic acidosis.

Lamivudine (Epivir) is a nucleoside reverse transcriptase inhibitor (NRTI) used to treat chronic hepatitis B infection and HIV infection.

One of the rare but serious adverse effects of lamivudine is lactic acidosis, which is a condition where the blood becomes too acidic due to the accumulation of lactate.Lactic acidosis can cause symptoms such as nausea, vomiting, abdominal pain, muscle weakness, rapid breathing, and low blood pressure.

Choice A is wrong because pancreatitis is not a common side effect of lamivudine.

Pancreatitis is an inflammation of the pancreas that can cause severe abdominal pain, nausea, vomiting, and fever.Pancreatitis is more likely to occur with other NRTIs such as didanosine (Videx) or stavudine (Zerit).

Choice C is wrong because hypothyroidism is not a common side effect of lamivudine.

Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormones, which regulate the metabolism and energy levels of the body.

Hypothyroidism can cause symptoms such as fatigue, weight gain, cold intolerance, dry skin, hair loss, and depression.

Hypothyroidism is more likely to occur with other drugs that interfere with thyroid function such as amiodarone (Cordarone) or lithium

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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

The nurse is caring for a newborn who was circumcised using a Gomco clamp 12 hours ago and notes that there is a small amount of blood on his diaper where his penis rests against it. The most appropriate nursing action would be to:

Correct Answer is C

Explanation

A nurse is caring for a client who has chronic hepatitis B infection and is taking lamivudine (Epivir). The nurse should monitor the client for which of the following adverse effects?

Correct Answer is B

Explanation

A nurse is performing an initial assessment of a newborn who was delivered vaginally at term with no complications. Which of the following findings should alert the nurse to a potential problem?

A nurse is assessing a newborn’s vital signs at 1 hour of age. Which of the following findings should the nurse report to the provider?

A nurse is caring for a newborn who has early-onset VKDB due to maternal use of anticoagulants during pregnancy. Which of the following interventions should the nurse anticipate for this newborn?

The nurse is teaching parents how to care for their son’s circumcision site after discharge from hospital using petroleum jelly and gauze dressing method. Which statement by parents indicates that they need further instruction?

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 hypoglycemia due to perinatal asphyxia. Which of the following findings should the nurse expect? (Select all that apply.)

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?

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?