Newborn Assessment > Maternal & Newborn
Exam Review
Fontanelles
Total Questions : 5
Showing 5 questions, Sign in for moreA nurse is assessing a newborn’s head and notices a swelling on the right parietal area.
The nurse suspects that this is a cephalohematoma.
What is the most likely cause of this condition?
Explanation
Birth trauma.A cephalohematoma is a collection of blood under the scalp of a newborn that forms a bulge.It is caused by rupture of blood vessels crossing the periosteum due to pressure or trauma on the fetal head during birth.This pressure or trauma may result from a prolonged second stage of labor, instrumental delivery, particularly forceps delivery, ventouse application, or the baby’s head squeezing through the birth canal.
Choice B is wrong because infection is not a cause of cephalohematoma, but a potential complication that may occur in some cases.
Choice C is wrong because dehydration is not a cause of cephalohematoma, but a possible consequence of anemia, which may result from blood loss.
Choice D is wrong because hemorrhage is not a cause of cephalohematoma, but a synonym for bleeding, which is what happens when the blood vessels rupture.
Normal ranges for newborn cephalohematoma are not applicable, as it is an abnormal condition that varies in size and severity.However, most cephalohematomas resolve on their own without intervention within weeks or months.
A nurse is teaching a new mother how to care for her infant’s fontanelles.
Which of the following statements by the mother indicates a need for further teaching?
Explanation
The mother should avoid touching the fontanelles because they are very sensitive.
This statement indicates a need for further teaching because it is a misconception.The fontanelles are not sensitive and can be gently touched and washed without causing any harm to the infant.
Choice A is correct because the fontanelles should be gently washed and dried when bathing the baby to prevent infection.
Choice B is correct because signs of bulging or sunken fontanelles can indicate increased or decreased intracranial pressure, which requires medical attention.
Choice D is correct because the fontanelles usually close by 18 months of age, but some variation is normal.
A nurse is measuring the head circumference of a 6-month-old infant.
The nurse notes that the anterior fontanel is 4 cm in size and the posterior fontanel is closed.
How should the nurse interpret these findings?
Explanation
The anterior fontanel is normal and the posterior fontanel is normal.
According to, the average size of the anterior fontanel is2.1 cm, and the median time of closure is13.8 months.The posterior fontanel generally closes2 to 3 monthsafter birth.
Therefore, a 6-month-old infant with an anterior fontanel of 4 cm and a closed posterior fontanel is within the normal range.
Choice A is wrong because the posterior fontanel is not delayed in closing.It usually closes by 3 months of age.
Choice C is wrong because the anterior fontanel is not enlarged.It can range from 0.6 cm to 3.6 cm with a mean of 2.1 cm.
Choice D is wrong because both the anterior and posterior fontanels are normal, not enlarged or delayed in closing.
Normal ranges for head circumference of a 6-month-old infant are39.59 to 44.34 cmfor girlsand40.89 to 45.34 cmfor boys, according to the CDC.
A nurse is examining a newborn’s head and observes a diffuse edema over the scalp that crosses the suture lines.
The nurse recognizes this as a caput succedaneum.
What should the nurse do next?
Explanation
Document the finding and monitor for resolution.Caput succedaneum is a harmless condition that causes swelling of the scalp due to pressure during delivery.It does not indicate any damage to the brain or the skull and usually resolves on its own within a few days.
Therefore, the nurse should document the finding and monitor for resolution.
Choice A is wrong because there is no need to notify the physician immediately.Caput succedaneum is not a medical emergency and does not require any intervention.
Choice C is wrong because applying ice packs to reduce swelling is not recommended.Ice packs can cause skin irritation, infection, or hypothermia in newborns.
Choice D is wrong because performing a neurological assessment is not necessary.Caput succedaneum does not affect the brain or the nervous system and does not cause any neurological symptoms.
A nurse is educating a group of parents about the functions of the fontanelles.
Which of the following statements by the nurse are correct? (Select all that apply.
Explanation
The fontanelles are soft spots on a baby’s head that have two main functions:
• They allow forrapid growth of the brainduring infancy
• They allow forpassage of the head through the birth canalby enabling the bony plates of the skull to flex
Choice A is wrong because the fontanelles do not allow for passage of blood from the scalp to the brain.The blood supply to the brain is provided by the internal carotid and vertebral arteries, which enter the skull through different openings
The fontanelles also allow forassessment of hydration statusandintracranial pressurein infants by palpating their size and shape.A sunken fontanelle may indicate dehydration, while a bulging fontanelle may indicate increased pressure within the skull
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