A nurse is assessing a child with iron deficiency anemia. Which of the following is NOT an expected finding?

Increased appetite

Pallor

Tachycardia

Brittle spoon-shaped nails

Answer and Explanation

The Correct Answer is A

A. Increased appetite is not an expected finding in a child with iron deficiency anemia. Children with iron deficiency anemia typically experience a reduced appetite or may develop pica (craving non-food substances) rather than an increased appetite.

B. Pallor is a common sign of iron deficiency anemia, as a lack of iron reduces the number of red blood cells and the amount of hemoglobin, leading to pale skin and mucous membranes.

C. Tachycardia is a compensatory response to anemia, as the heart works harder to deliver oxygen to tissues due to a reduced capacity of the blood to carry oxygen.

D. Brittle spoon-shaped nails (koilonychia) are a classic physical finding in iron deficiency anemia, caused by the reduced oxygen delivery to the nails and skin.

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Correct Answer is C

Explanation

A. Gross motor skill development is important for an infant’s overall development, but it is not the primary focus when caring for an infant with a cleft palate. Gross motor skills typically develop at a normal rate unless there are additional concerns.

B. Fine motor skill development is also important, but for an infant with a cleft palate, the primary concern is related to communication and feeding difficulties. Fine motor development generally follows the same trajectory unless there are complicating factors.

C. Speech and language acquisition is the most important area to focus on when planning care for an infant with a cleft palate. A cleft palate can significantly impact the infant’s ability to produce sounds and develop normal speech patterns. Early intervention and support from speech therapists are essential to address these issues.

D. Cognitive development is vital for all infants, but cleft palate primarily affects speech and feeding, making speech and language acquisition the most immediate concern for overall development.

A. Alteration in pupil size and reactivity and increased motor response B. Extension or flexion posturing and weight gain C. Tachycardia and alteration in pupil size and reactivity D. Cheyne-Stokes respirations and alteration in pupil size

Correct Answer is D

Explanation

A. While alterations in pupil size and reactivity are signs of increased ICP, increased motor response is not a late sign and typically reflects an early sign of brain dysfunction.

B. Extension or flexion posturing may occur with increased ICP, but weight gain is not a sign of ICP.

C. Tachycardia can occur early in ICP, but it does not typically present as a late sign. Altered pupil size and reactivity may occur, but these are not exclusive to late ICP signs.

D. This is the correct answer. Cheyne-Stokes respirations, which are characterized by alternating periods of apnea and deep breathing, are a late sign of increased ICP in infants. Additionally, changes in pupil size (such as dilated or non-reactive pupils) are a late indicator of increasing intracranial pressure.

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A nurse is assessing a child with iron deficiency anemia. Which of the following is NOT an expected finding?

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with the plan of care for a 6-month-old infant who has a cleft palate. Which area should the nurse consider when addressing the child's overall development?

Correct Answer is C

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Correct Answer is D

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