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 ["A","B","C","D","E"]
Explanation
The correct answer is choice A, B, C, D and E.All of these are possible modes of transmission for hepatitis B virus (HBV), which is a viral infection that attacks the liver and can cause both acute and chronic disease.The virus is most commonly transmitted from mother to child during birth and delivery, as well as through contact with blood or other body fluids during sex with an infected partner, unsafe injections or exposures to sharp instruments.
Choice A is correct because unprotected sexual contact can expose a person to the blood, semen, or vaginal fluids of an infected partner.
Choice B is correct because sharing drugs, needles, or “works” when using drugs can expose a person to the blood of an infected person.
Choice C is correct because poor infection control practices in medical settings can expose a person to contaminated needles or syringes or sharp objects that have been used on an infected person.
Choice D is correct because sharing of blood sugar (diabetes) testing equipment can expose a person to the blood of an infected person.
Choice E is correct because needle sticks or sharps exposures on the job can expose a person to the blood of an infected
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.
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