A nurse is performing a newborn assessment and notes depressed fontanels. Which of the following is true regarding depressed fontanels in newborn assessment?
Depressed fontanelles are only seen in premature newborns.
Depressed fontanelles indicate infection.
Depressed fontanelles are a sign of dehydration.
Depressed fontanelles are a normal finding in newborns.
The Correct Answer is C
Choice A rationale
Depressed fontanelles are not exclusive to premature newborns. They can occur in both premature and full-term infants and are not an indicator of prematurity.
Choice B rationale
Depressed fontanelles do not indicate infection. Infections in newborns typically present with other symptoms such as fever, irritability, and poor feeding.
Choice C rationale
Depressed fontanelles are a sign of dehydration in newborns. When a newborn is dehydrated, the fontanelles can appear sunken due to the lack of fluid in the body.
Choice D rationale
Depressed fontanelles are not a normal finding in newborns. Normally, fontanelles should be flat or slightly curved inward. A depressed fontanelle is a clinical sign that requires further evaluation and intervention.
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Correct Answer is B
Explanation
Choice A rationale
Erythema toxicum is a common, benign rash in newborns but does not cause swelling that crosses suture lines.
Choice B rationale
A caput succedaneum is swelling of the scalp that crosses suture lines and is caused by prolonged pressure on the head during delivery.
Choice C rationale
Mongolian spots are benign, flat, congenital birthmarks with wavy borders and irregular shapes, typically found on the lower back and buttocks, not the head.
Choice D rationale
A cephalhematoma is a collection of blood between the skull bone and its periosteum that does not cross suture lines. .
Correct Answer is A
Explanation
Choice A rationale
Given the neonate’s symptoms and critically low blood glucose level (30 mg/dL), the most urgent action is to address the hypoglycemia. Therefore, the nurse shouldadminister a bolus of intravenous glucose (Option A). This immediate intervention is crucial to stabilize the neonate and prevent further complications associated with hypoglycemia.
Choice B rationale
While monitoring blood glucose levels is important, waiting 30 minutes to reassess without immediate intervention could allow the hypoglycemia to worsen, potentially leading to severe complications such as seizures or brain damage. Immediate treatment is necessary to stabilize the neonate.
Choice C rationale
Although feeding can help increase blood glucose levels, the neonate’s current symptoms (jitteriness, poor feeding, weak cry, and irritability) suggest that they may not be able to effectively feed. Additionally, the blood glucose level is critically low and requires more rapid correction than feeding alone can provide.
Choice D rationale
While maintaining an appropriate body temperature is important, the neonate’s temperature (36.1°C) is not critically low. The primary concern here is the hypoglycemia, which needs to be addressed immediately. Placing the neonate under a radiant warmer does not directly address the low blood glucose level.