A nurse is assessing the fontanels of a crying newborn and notes that the posterior fontanel pulsates and briefly bulges. What do these findings indicate?

Increased intracranial pressure

Dehydration

Overhydration

These are normal findings

Answer and Explanation

The Correct Answer is D

A. Increased intracranial pressurE. Pulsation and bulging of the fontanel may be signs of

increased intracranial pressure in infants. However, it is important to differentiate between normal fontanel characteristics and abnormal signs of elevated intracranial pressure. In this case, the pulsation and bulging are likely normal responses to crying and changes in intracranial pressure during the newborn period.

B. Dehydration: Dehydration typically presents with sunken fontanels rather than pulsation and bulging. Dehydration is a serious condition that requires prompt assessment and intervention, but it is not indicated by the findings described in the scenario.

C. Overhydration: Overhydration is not typically associated with pulsation and bulging of the fontanel. Overhydration may lead to fluid overload and edema but does not directly affect fontanel characteristics.

D. These are normal findings: Pulsation and brief bulging of the fontanel in response to crying are considered normal findings in newborns. Fontanels allow for the flexibility of the skull bones during childbirth and provide space for brain growth during infancy. Pulsation and bulging may occur temporarily during crying or changes in intracranial pressure and are not necessarily

indicative of pathology.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. "This is a primitive reflex known as the palmar grasp.": The palmar grasp reflex is a primitive reflex observed in newborns where they automatically grasp onto objects (or fingers) that touch

their palms. This reflex typically disappears by around 6 months of age.

B. "This is a protective reflex known as rooting.": Rooting is a reflex where newborns turn their head and open their mouth in response to cheek or mouth stimulation, facilitating breastfeeding. It is not related to grasping objects with the hands.

C. "This is a primitive reflex known as the plantar grasp.": The plantar grasp reflex is similar to the palmar grasp but occurs when pressure is applied to the sole of the foot. It is unrelated to grasping objects with the hands.

D. "This is a protective reflex known as the Moro reflex.": The Moro reflex, also known as the startle reflex, involves the newborn's arms and legs extending and then flexing in response to a sudden movement or loud noise. It is not related to grasping objects with the hands.

A. "Can you stand very still while I feel how warm you are?" B. "I am going to listen to your heart." C. "Can I listen to your lungs?" D. "I am going to take your blood pressure now."

Correct Answer is B

Explanation

A. "Can you stand very still while I feel how warm you are?": Toddlers may have difficulty understanding abstract requests or instructions. Asking a toddler to stand still to feel warmth may not effectively communicate the purpose of the assessment and may lead to confusion or

resistance.

B. "I am going to listen to your heart.": This statement provides clear, simple language that the toddler can understand. It prepares the child for the assessment and helps establish trust and cooperation.

C. "Can I listen to your lungs?": While this statement is appropriate for assessing respiratory sounds, it may not be as clear or specific as stating the intention to listen to the heart. Toddlers may not understand the term "lungs" as readily as "heart."

D. "I am going to take your blood pressure now.": This statement may cause anxiety or fear in the toddler, especially if they are unfamiliar with the procedure. It is important to prepare the child for each aspect of the assessment in a developmentally appropriate manner.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is assessing the fontanels of a crying newborn and notes that the posterior fontanel pulsates and briefly bulges. What do these findings indicate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A new mother shows the nurse that her baby grasps her finger when she touches the baby's palm. How might the nurse respond to this information?

Correct Answer is A

Explanation

A nurse is caring for a toddler. Which of the following statements should the nurse use when preparing to obtain the child's vital signs?

Correct Answer is B

Explanation

A nurse is caring for a 12-month-old toddler who is hospitalized and confined to a room with contact precautions in place. Which of the following toys should the nurse recommend in orderto meet the developmental needs of the client?

The nurse is conducting a physical examination of a child following a comprehensive health history. What should be the focus of the physical examination?

The nurse caring for newborns knows that infants exhibit phenomenal increases in their gross motor skills over the first 12 months of life. Which statements accurately describe the typical infant's achievement of these milestones? Select all that apply.

The nurse is performing a health history on a 6-year-old boy who is having trouble adjusting to school. Which question would be most likely to elicit valuable information?

A nurse is monitoring an infant who is 3 months old and has sneezing, coughing, nasal congestion, intermittent fever, and apneic spells. These nurse should recognize these findings are associated with which of the following diagnoses?

A parent of a toddler asks a nurse at a well-child visit how the child's frequent tempertantrums can best be handled. Which of the following actions should the nurse suggest to the parent?

The nurse is caring for a 7-month-old girl during a well-child visit. Which intervention is most appropriate for this child?

The nurse teaches parents of adolescents that adolescents need the support of parents and nurses to facilitate healthy lifestyles. What should be a priority focus of this guidance?