A nurse palpates an infant’s anterior fontanelle and notes that it feels soft and flat when lying down, but slightly elevated when sitting up or crying.

What should be included in documentation?

Normal finding.

The anterior fontanelle is the soft spot on the top of an infant’s head that allows for brain growth and skull expansion.

It normally feels soft and flat when the infant is lying down, and may bulge slightly when the infant is sitting up or crying due to increased blood flow and pressure.

This is not a sign of any problem and should be documented as a normal finding.

Dehydration is wrong because dehydration would cause the fontanelle to feel sunken or depressed, not elevated. Dehydration can also cause other signs such as dry mouth, decreased urine output, and lethargy.

Increased intracranial pressure is wrong because increased intracranial pressure would cause the fontanelle to feel tense or bulging at all times, not only when sitting up or crying. Increased intracranial pressure can also cause other signs such as vomiting, irritability, seizures, and altered level of consciousness.

Infection is wrong because infection would cause the fontanelle to feel warm or tender, not elevated. Infection can also cause other signs such as fever, rash, poor feeding, and fussiness.

Monitor for signs of jaundice.A cephalohematoma is a collection of blood under the scalp that occurs due to trauma or pressure during delivery.It may increase the risk of jaundice in the newborn due to the breakdown of red blood cells and the release of bilirubin.Jaundice is a condition that causes yellowing of the skin and eyes due to high levels of bilirubin in the blood.Monitoring for signs of jaundice is important to prevent complications such as brain damage or kernicterus.

Apply pressure dressing over the area.This is wrong because applying pressure may increase the bleeding and cause more damage to the scalp and skull.A cephalohematoma does not require any treatment and usually resolves on its own within weeks or months.

Administer antibiotics as prescribed.This is wrong because antibiotics are not indicated for a cephalohematoma unless there is evidence of infection.Infection is a rare complication that may lead to osteomyelitis or meningitis.Antibiotics should be used only if prescribed by a doctor based on clinical signs and laboratory tests.

Elevate the head of the bed.This is wrong because elevating the head of the bed may not have any effect on a cephalohematoma.It may also cause discomfort or compromise the airway of the newborn.The position of the baby should be adjusted according to their comfort and safety.