Clinical Manifestations of Shaken Baby Syndrome
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A nurse is preparing to assess an infant. Which of the following is an expected finding of shaken baby syndrome? (Select all that apply)
☐ Retinal hemorrhage
☐ Altered level of consciousness
☐ Sunken fontanels
☐ Increased head circumference
☐ Respiratory distress
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In this nursing assessment question, we are identifying the expected findings for an infant with Shaken Baby Syndrome. This is a select all that apply question, so multiple options may be correct.
Shaken Baby Syndrome (SBS) Assessment
Shaken Baby Syndrome is a form of abusive head trauma caused by vigorous shaking. It leads to shearing forces on the brain and blood vessels.
Pathophysiology
* Shearing Forces: Movement of the brain within the skull.
* Intracranial pressure: Swelling and bleeding increase pressure.
Let's evaluate the first option, retinal hemorrhage. This is a classic hallmark sign of shaken baby syndrome due to the extreme rotational forces on the eyes.
1. Retinal hemorrhage
So, we will select retinal hemorrhage as a correct finding.
Next is altered level of consciousness. Because of brain swelling, subdural hematomas, and hypoxic-ischemic injury, the infant often appears lethargic or unresponsive.
2. Altered level of consciousness
This is definitely an expected finding, so we mark it green.
The third option is sunken fontanels. This is actually a sign of dehydration.
3. Sunken fontanels
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