A nurse is assessing a 2-year-old toddler. Which of the following findings should the nurse expect?
Natural loss of deciduous teeth
Nontender, protruding abdomen
Palpable fontanels
Head circumference exceeds chest circumference
The Correct Answer is B
A. Incorrect. The natural loss of deciduous (baby) teeth typically begins around 6 years of age, not at 2 years old.
B. Correct. Toddlers often have a nontender, protruding abdomen due to their underdeveloped abdominal muscles.
C. Incorrect. The fontanels (soft spots on the baby's head) should be closed by 18-24 months of age. Palpable fontanels at 2 years old could indicate abnormal cranial development.
D. Incorrect. It is not typical for a 2-year-old's head circumference to exceed their chest circumference. Head circumference is usually greater in infants but gradually becomes similar to chest circumference by 1-2 years of age.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Bleeding gums are common during pregnancy due to hormonal changes that make gums more sensitive and prone to bleeding. This is not typically a sign of a serious condition and can usually be managed with good oral hygiene.
B. Faintness or lightheadedness upon rising is common in pregnancy due to blood pressure changes. This can often be managed with lifestyle modifications such as rising slowly, staying hydrated, and avoiding prolonged standing.
C. Swelling of the face during pregnancy can be an early sign of preeclampsia, a serious condition characterized by high blood pressure and organ damage. This is a concerning symptom that requires immediate evaluation by a healthcare provider.
D. Urinary frequency is a common and usually benign symptom during pregnancy, especially in the first and third trimesters due to hormonal changes and pressure on the bladder. It does not typically require urgent reporting unless accompanied by other symptoms such as pain or burning during urination, which could indicate a urinary tract infection.
Correct Answer is C
Explanation
Based on the client's sudden right-sided numbness, weakness of the arm and leg, and distinct right-sided facial droop, the nurse should suspect a possible stroke and prioritize immediate interventions. After reporting the findings to the healthcare provider and receiving prescriptions, the nurse should implement the following intervention:
Notify the stroke team to assist with acute assessment and management. A stroke is a medical emergency that requires urgent intervention and specialized care. The stroke team is trained to quickly assess and manage stroke patients, including performing necessary diagnostic tests and initiating appropriate treatment. In this case, a STAT computerized tomography (CT) scan of the head has been ordered, indicating the need to evaluate the client's brain for possible ischemic or hemorrhagic stroke.
While keeping the bed in the lowest position and initiating seizure and fall precautions may be important considerations for stroke patients, notifying the stroke team takes precedence as they are specifically trained to manage acute stroke cases.
Administering aspirin to prevent further clot formation and platelet clumping is not appropriate without further assessment and confirmation of the type of stroke.
Additionally, testing for a swallowing reflex and performing communication deficit assessments can be important components of the overall stroke management plan, but they should be carried out by the stroke team or as directed by the healthcare provider.
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