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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. 1 cup of cooked rice is equivalent to 2 oz of grains, which is double the recommended amount.
B. 1 cup of ready-to-eat cereal flakes is equivalent to 1 oz of grains, which meets the recommendation precisely.
C. 1?2 slice of whole wheat bread is equivalent to 0.5 oz of grains, which is half the recommended amount.
D. 11?2 flour tortilla is equivalent to 3 oz of grains, which is triple the recommended amount.
Correct Answer is D
Explanation
A. Controls impulsive feelings: Preschoolers are still developing their ability to control impulses. While they may begin to understand the concept of rules and consequences, complete control over impulsive feelings is not typically expected at this stage.
B. Expresses need for privacy: Preschoolers may begin to show a growing awareness of privacy but may not consistently express this need or fully understand its implications. This is more commonly seen in older children and adolescents.
C. Builds a collection of cards: Building a collection of cards is not a typical developmental task for preschoolers. While they may engage in collecting objects, the items they collect are often related to their interests and may vary widely.
D. Participates in imaginary play: Imaginary play is a significant aspect of preschoolers' development. They often engage in make-believe scenarios, role-playing, and using objects symbolically to represent other objects. This type of play fosters creativity, social skills, and cognitive development in preschool-aged children.
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