A nurse is assessing the fontanelles of an infant. Which finding should the nurse consider normal?
Depressed and sunken fontanelles.
Flat and firm fontanelles.
Slightly bulging fontanelles.
Pulsating fontanelles.
The Correct Answer is C
A. Incorrect. Depressed and sunken fontanelles are signs of dehydration and should be evaluated promptly.
B. Incorrect. Flat and firm fontanelles may indicate normal hydration, but slight bulging is considered normal in infants.
C. Correct. Slightly bulging fontanelles can be normal in infants due to crying, coughing, or changes in intracranial pressure. However, severely bulging or depressed fontanelles are concerning and require further evaluation.
D. Incorrect. Pulsating fontanelles are a normal finding and are related to the pulsations of blood flow in the area.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Incorrect. The Babinski reflex, where the big toe extends and the other toes fan out, is normal in infants but typically disappears by the age of 2.
B. Correct. The Moro reflex is a normal startle response in newborns. It involves symmetrically spreading the arms and then bringing them back to the body when the infant experiences a sudden change in position or stimulation.
C. Incorrect. The tonic neck reflex, also known as the "fencing" reflex, is a normal infantile reflex but typically disappears by 6 months.
D. Incorrect. The plantar grasp reflex, where the toes curl in when the sole of the foot is touched, is normal in infants but typically disappears by 9 months.
Correct Answer is A
Explanation
A. Correct. The Ortolani maneuver is used to assess for developmental dysplasia of the hip (DDH) in infants. It involves gently abducting the hips while applying gentle pressure to feel for any instability.
B. Incorrect. The Barlow maneuver is also used to assess for DDH, but it involves adducting the hips.
C. Incorrect. The Phalen maneuver is used to assess for carpal tunnel syndrome, which is not relevant to hip stability.
D. Incorrect. Tinel's sign is used to assess for nerve compression, typically in the wrist, and is not relevant to hip stability.
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