A nurse is assessing a 2-year-old toddler.
Which of the following findings should the nurse expect?
Nontender, protruding abdomen.
Head circumference exceeds chest circumference.
Palpable fontanels.
Natural loss of deciduous teeth
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The Correct Answer is A
Answer and explanation.
The correct answer is choice A. A nontender, protruding abdomen is a normal finding for a 2year-old toddler. This is due to the immature development of the abdominal muscles and the relatively large size of the liver and kidneys in relation to the rest of the body.
Choice B is wrong because the head circumference should be equal to or less than the chest circumference by age 2. A head circumference that exceeds the chest circumference could indicate hydrocephalus or other neurological problems.
Choice C is wrong because the fontanels, or soft spots on the skull, should be closed by age 18 months. Palpable fontanels could indicate dehydration, malnutrition, or congenital disorders.
Choice D is wrong because the natural loss of deciduous teeth, or baby teeth, usually begins around age 6. Premature loss of teeth could indicate dental caries, trauma, or endocrine disorders.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Explanation:
"I will use a cool-mist vaporizer in my baby's room." This statement demonstrates an understanding of the teaching. Using a cool-mist vaporizer can help maintain moisture in the air and alleviate nasal congestion in infants.
Incorrect:
B- "I will leave my baby's bib on while he is sleeping." This statement indicates a lack of understanding. It is not safe to leave a bib on an infant while they are sleeping as it can pose a suffocation risk.
C- "I will leave the plastic covering on the crib mattress." This statement indicates a lack of understanding. The plastic covering on the crib mattress should be removed as it can pose a suffocation hazard.
D- "I will lay my baby's head on a pillow while he is in the crib." This statement indicates a lack of understanding. Pillows should not be used in the crib for infants as they can increase the risk of suffocation and SIDS (Sudden Infant Death Syndrome).
Correct Answer is B
Explanation
Choice A reason
Administering naloxone to the newborn is not appropriate. Naloxone is an opioid antagonist used to reverse the effects of opioid overdose in adults. It is not typically used for newborns with neonatal abstinence syndrome. The management of NAS is primarily supportive, and medications may be prescribed to help manage specific withdrawal symptoms, but naloxone is not a standard treatment for NAS.
Choice B reason:
Minimizing noise in the newborn's environment is a crucial action in the plan of care is the correct action to be included. Newborns experiencing NAS can be easily overstimulated, and loud noises can exacerbate their withdrawal symptoms and distress. Creating a calm and quiet environment helps reduce agitation and promotes better sleep and overall comfort.
Choice C reason
Swaddling the newborn with his leg extended is not appropriate in this case. Swaddling can be beneficial for some newborns, but the specific positioning and swaddling techniques should be individualized based on the newborn's needs and preferences. Extending the newborn's legs may not necessarily be the best approach, as it may not provide comfort or address the symptoms associated with NAS.
Choice D reason:
Maintaining eye contact with the newborn during feedings is not appropriate in this case. While maintaining eye contact during feedings is an essential aspect of bonding and promoting parent-newborn attachment, it may not be the primary focus in managing neonatal abstinence syndrome. The plan of care for a newborn with NAS would primarily involve managing withdrawal symptoms, providing comfort measures, and addressing the newborn's unique needs during this challenging period.

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