Question

A nurse is preparing to assess an infant who has shaken baby syndrome. Which of the following is an expected finding? (Select all that apply)

A. Sunken fontanels
B. Respiratory distress
C. Retinal hemorrhage
D. Altered LOC
E. Increase in head circumference

Answer 1

Expected findings in an infant with shaken baby syndrome include respiratory distress, retinal hemorrhage, altered LOC, and potentially an increase in head circumference. Sunken fontanels are typically not associated with this condition, but bulging fontanels can be a sign due to increased intracranial pressure.

Step-by-step explanation:

A nurse preparing to assess an infant with shaken baby syndrome should expect a number of clinical findings that result from the violent shaking or impact to the infant's head. Expected findings for shaken baby syndrome could include:

• Respiratory distress: Infants may have difficulty with breathing due to brain swelling or injuries.
• Retinal hemorrhage: Forceful shaking can cause bleeding in the retina of the eyes.
• Altered Level of Consciousness (LOC): The infant may exhibit unusual sleepiness, difficulty staying awake, or decreased alertness due to brain injury.
• An increase in head circumference: This can indicate brain swelling due to injury.

It should be noted that sunken fontanels are typically not a finding in shaken baby syndrome; instead, a bulging fontanel could be a sign due to the increased intracranial pressure from brain swelling.