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 ["A","D","E","F"]
Explanation
Choice A rationale
Bottles can be put in the dishwasher, boiled, or cleaned with hot soapy water to ensure they are thoroughly sanitized and safe for the infant.
Choice B rationale
Holding the baby in a supine position during feedings is incorrect because it increases the risk of aspiration. The baby should be held in a semi-upright position.
Choice C rationale
Only burping the baby after they have finished the entire feeding is incorrect because it can lead to discomfort and gas buildup. The baby should be burped during and after feedings.
Choice D rationale
Always holding the bottle while feeding and not propping the bottle is correct as it prevents choking and ensures the baby is feeding safely.
Choice E rationale
Keeping the nipple full of formula throughout the feeding is correct as it prevents the baby from swallowing air, which can cause gas and discomfort.
Choice F rationale
Prepared formula can be kept in the refrigerator for 48 hours, ensuring it remains safe and free from bacterial growth.
Correct Answer is ["D","F","G","H"]
Explanation
Choice A rationale
Flexion of arms is a normal finding in newborns and does not indicate respiratory distress.
Choice B rationale
Caput succedaneum is a common condition where the scalp swells due to pressure during delivery. It does not indicate respiratory distress.
Choice C rationale
A heart rate of 158 bpm is within the normal range for newborns and does not indicate respiratory distress.
Choice D rationale
A respiratory rate of 66/min is above the normal range (30-60 breaths per minute) and indicates respiratory distress.
Choice E rationale
Acrocyanosis is common in newborns and does not indicate respiratory distress.
Choice F rationale
Subcostal retractions indicate increased work of breathing and are a sign of respiratory distress.
Choice G rationale
Nasal flaring is a sign of respiratory distress as it indicates increased effort to breathe.
Choice H rationale
Grunting is a sign of respiratory distress as it indicates difficulty in maintaining lung expansion.