A nurse is assessing a 6-month-old infant at a well-child visit. Which of the following findings should the nurse expect?

Lateral incisors

Closed posterior fontanel

Sitting steadily without support

Uses thumb and index fingers in a pincer grasp

Answer and Explanation

The Correct Answer is B

The posterior fontanel, located on the back of the head, usually closes by the age of 2-3 months. By 6 months of age, it is expected to be closed.

By 6 months of age, infants typically do not have their lateral incisors. The primary incisors, which are the central incisors in the lower and upper jaw, usually erupt first around 6-10 months of age.

At around 8 months of age, most infants are able to sit steadily without support. They can maintain an upright sitting position and may even start to reach for objects or play in a sitting position.

At 6 months of age, infants are still in the developmental stage of exploring objects and refining their motor skills. They typically use a palmar grasp, where they grasp objects with their entire hand. The pincer grasp, which involves using the thumb and index finger to pick up small objects, usually develops around 9-10 months of age.

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Correct Answer is C

Explanation

A. It’s usually best to build trust and rapport first with non-invasive assessments. Starting with a potentially uncomfortable procedure like looking in the ears may cause distress and make the rest of the exam more difficult.

B.Examining the tympanic membrane before the head and neck might still be too early in the assessment and could cause the child to become uncooperative for subsequent steps. If the child becomes upset, it could complicate the rest of the physical exam, making it harder to complete.

C.Performing the ear examination at the end allows the nurse to build trust and rapport throughout the visit. The child is less likely to become distressed too early in the exam, which helps maintain cooperation for as long as possible.If the child does become upset, it is at the end of the visit, and the more critical assessments have already been completed.

D.If the ear exam causes distress, it may make the child uncooperative for important assessments like auscultating the heart and lungs.

A. The child has a congenital immunodeficiency. B. The child is currently taking antibiotics for otitis media. C. The child has a cough and a temperature of 37.7° C (99.9" F) D. The child's temperature after the last set of immunizations was 38.3 C(101)

Correct Answer is A

Explanation

Children with congenital immunodeficiencies have compromised immune systems and may not be able to mount an adequate immune response to the vaccine. Administering live vaccines, such as MMR, to these children can potentially cause severe complications.

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A nurse is assessing a 6-month-old infant at a well-child visit. Which of the following findings should the nurse expect?

Nursing Test Bank

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