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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Nasal flaring and grunting are signs of respiratory distress in a newborn and should alert the nurse to a potential problem.
The nurse should monitor the newborn’s respiratory rate, oxygen saturation, and chest movements, and notify the provider if the symptoms persist or worsen.
Choice A is wrong because molding of the head is a normal finding in a newborn who was delivered vaginally.
It is caused by the pressure of the birth canal on the skull bones and usually resolves within a few days.
Choice B is wrong because acrocyanosis of hands and feet is a normal finding in a newborn during the first 24 hours of life.
It is caused by poor peripheral circulation and does not indicate hypoxia or cyanosis.
Choice D is wrong because vernix caseosa on skin folds is a normal finding in a newborn.
It is a white, cheesy substance that protects the skin from amniotic fluid and helps with thermoregulation.
It usually disappears within a few days.
Correct Answer is A
Explanation
The correct answer is choice A. Administer fresh frozen plasma.This is because fresh frozen plasma contains clotting factors that can help stop the bleeding caused by vitamin K deficiency.Vitamin K is needed for the synthesis of clotting factors in the liver, but newborns have low levels of vitamin K and may develop vitamin K deficiency bleeding (VKDB) if they do not receive prophylaxis at birth.VKDB can manifest as bleeding in various sites, such as the skin, mucous membranes, umbilicus, gastrointestinal tract, or central nervous system.
Choice B is wrong because packed red blood cells do not contain clotting factors and will not correct the underlying deficiency of vitamin K.
Choice C is wrong because intravenous immunoglobulin is used to treat immune-mediated thrombocytopenia, not vitamin K deficiency.
Choice D is wrong because recombinant erythropoietin is used to stimulate red blood cell production in anemia, not to treat bleeding disorders.
Early-onset VKDB occurs within 24 hours of birth and is associated with maternal use of drugs that interfere with vitamin K metabolism, such as anticoagulants, anticonvulsants, or antituberculosis drugs.
These drugs induce the enzymes that break down vitamin K in the fetal liver
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