A mother brings her 2-month-old daughter in for an examination and says, "My daughter rolled over against the wall, and now I have noticed that she has this spot that is soft on the top of her head. Is something terribly wrong?" How should the nurse respond?
"Perhaps that could be a result of your dietary intake during pregnancy."
"That 'soft spot' may be an indication of cretinism or congenital hypothyroidism."
"That 'soft spot is normal, and actually allows for growth of the brain during the first year of your baby's life."
"Your baby may have craniosynostosis, a disease of the sutures of the skull."
The Correct Answer is C
A. "Perhaps that could be a result of your dietary intake during pregnancy": This statement does not address the mother's concerns about the soft spot and shifts the focus away from the immediate issue. The soft spot, or fontanelle, is a normal anatomical feature and is not related to maternal dietary intake during pregnancy.
B. "That 'soft spot' may be an indication of cretinism or congenital hypothyroidism": This statement is misleading. While developmental delays can be associated with congenital hypothyroidism, the presence of a soft spot on a 2-month-old’s head is a normal finding, not a direct indication of a metabolic disorder.
C. "That 'soft spot' is normal, and actually allows for growth of the brain during the first year of your baby's life": This response provides accurate information about the anterior fontanelle, which is a normal feature in infants. The fontanelle allows for skull growth as the brain expands during the early months of life. It typically closes by 12-18 months of age.
D. "Your baby may have craniosynostosis, a disease of the sutures of the skull": This statement could cause unnecessary alarm for the mother. Craniosynostosis is a condition where one or more of the sutures in a baby’s skull fuse prematurely, but it would typically present with other signs such as an abnormal head shape. A soft spot on its own does not indicate this condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Is impaired in a patient with cataracts: Cataracts primarily cause lens opacity, leading to blurry vision and reduced acuity. They do not directly affect extraocular muscle function, which is controlled by cranial nerves rather than the lens.
B. Is always decreased in the older adult: Aging can cause minor changes in eye movement speed and coordination, but significant impairment is not inevitable. Extraocular muscle function remains intact unless affected by neurological conditions such as cranial nerve palsy.
C. Is stimulated by cranial nerves (CNS) I and II: Cranial nerve I (olfactory) is responsible for smell, and cranial nerve II (optic) transmits visual signals to the brain. Neither nerve controls eye movement, which is instead governed by different cranial nerves.
D. Is stimulated by cranial nerves III, IV, and VI: The oculomotor (III), trochlear (IV), and abducens (VI) nerves control extraocular muscle movement. They coordinate eye positioning, alignment, and smooth tracking, ensuring proper function of the visual system.
Correct Answer is A
Explanation
A. Maxillary sinusitis: The symptoms described, including facial pain, fever, malaise, swollen turbinates, purulent nasal discharge, and dull, throbbing pain in the cheeks and teeth, are consistent with maxillary sinusitis. The maxillary sinuses are located in the cheeks, and inflammation or infection in this area can lead to referred pain in the teeth and facial areas. Tenderness upon palpation of the maxillary sinus area further supports this diagnosis.
B. Posterior epistaxis: Posterior epistaxis refers to bleeding from the back of the nasal cavity. While it can be associated with nasal pain, it does not typically present with fever, malaise, purulent discharge, or sinus-related pain.
C. Frontal sinusitis: Frontal sinusitis involves inflammation of the frontal sinuses located above the eyes, which may cause pain in the forehead and around the eyes. The patient's complaint of cheek and teeth pain is more indicative of maxillary sinusitis rather than frontal sinusitis.
D. Nasal polyps: Nasal polyps are non-cancerous growths that can occur in the nasal passages or sinuses, often leading to obstruction and difficulty breathing. While they can be associated with sinusitis, the acute presentation of fever, malaise, and purulent discharge, along with facial pain, is more indicative of an active infection, such as maxillary sinusitis.
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