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.
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Related Questions
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.
Correct Answer is A
Explanation
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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