A nurse is performing a head-to-toe assessment of a newborn.
What finding should alert the nurse to a potential problem with the newborn’s fontanelles?
Sunken fontanelles
Bulging fontanelles
Diamond-shaped anterior fontanelle
Triangular posterior fontanelle.
The Correct Answer is B
Bulging fontanelles. Bulging fontanelles can be a sign of increased intracranial pressure or intracranial and extracranial tumors. This is a potential problem for the newborn’s brain and health and should be evaluated by imaging studies.
Choice A is wrong because sunken fontanelles are usually a sign of dehydration, which is not a problem with the fontanelles themselves, but with the fluid balance of the newborn.
Choice C is wrong because a diamond-shaped anterior fontanelle is normal for a newborn. The anterior fontanelle is the largest and most important for clinical evaluation. It has an average size of 2.1 cm and a median time of closure of 13.8 months.
Choice D is wrong because a triangular posterior fontanelle is also normal for a newborn. The posterior fontanelle is smaller than the anterior one and normally closes by 8 weeks.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Apply a thin ribbon of ointment along the inner canthus of each eye.This is the recommended method for administering erythromycin ointment to a newborn’s eyes as prophylaxis for gonorrhea and chlamydia infections.The ointment should be applied into the conjunctival sac to avoid accidental injury to the eye.
ChoiceBis wrong because the eyes should not be wiped off after applying the ointment.The ointment will gradually dissolve and disperse over the eye surface.
ChoiceCis wrong because the medication is an ointment, not a drop.
A drop would not provide adequate coverage of the eye and would be more likely to cause irritation
Correct Answer is B
Explanation
Monitor the newborn for signs of jaundice and anemia.
This is because the newborn has a positive Coombs test, which means that there are antibodies against the newborn’s red blood cells (RBCs) in the blood.
These antibodies can cause hemolysis (destruction) of the RBCs, leading to jaundice (yellowing of the skin and eyes due to high bilirubin levels) and anemia (low RBC count and hemoglobin levels).The most likely cause of the positive Coombs test in this case is ABO incompatibility, which occurs when the mother has type O blood and the newborn has type A or B blood.
Choice A is wrong because administering hepatitis B immune globulin (HBIG) to the newborn within 12 hours of birth is indicated for newborns whose mothers are positive for hepatitis B surface antigen (HBsAg), which is not the case here.
Choice C is wrong because obtaining a blood sample from the newborn for blood typing and crossmatching is not necessary, as the newborn’s blood type is already known to be A positive.
Choice D is wrong because preparing the newborn for exchange transfusion with type O negative blood is a treatment option for severe cases of hemolytic disease of the newborn (HDN), which is not evident in this scenario.Exchange transfusion involves replacing the newborn’s blood with donor blood to remove antibodies and bilirubin.
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