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.

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Correct Answer is B

Explanation

A. Vary the child's schedule each day: While some variation in activities may be beneficial, providing a stable and predictable routine can also promote a sense of security and stability for the child during hospitalization.

B. According to Erikson's psychosocial development theory, the psychosocial stage for a 10- year-old child is industry versus inferiority. During this stage, children are developing a sense of competence by mastering new skills and tasks. Encouraging the child to complete school work supports this developmental stage by fostering a sense of accomplishment and competence. It

also helps maintain a sense of normalcy and continuity with academic activities despite the hospitalization.

C. Discourage visits from the client's friends: Social interaction with peers is important for the child's emotional well-being and development. Discouraging visits from friends would likely have a negative impact on the child's psychosocial needs during hospitalization.

D. Provide a daily session with a play therapist: While play therapy may be beneficial for addressing emotional needs, it may not directly address the child's psychosocial development according to Erikson's theory. Encouraging completion of school work aligns more closely with the developmental tasks of this stage.

A. Puberty might be delayed if scrotal changes have not occurred by the age of 11 years. B. Growth spurts in height occur toward the end of midpuberty. C. Changes in the voice signal the beginning of puberty. D. Gynecomastia commonly occurs during late puberty.

Correct Answer is A

Explanation

A. Puberty might be delayed if scrotal changes have not occurred by the age of 11 years: This statement is accurate because the lack of scrotal changes by the age of 11 years may indicate delayed puberty, prompting further evaluation by a healthcare provider.

B. Growth spurts in height occur toward the end of midpuberty: Growth spurts in height typically occur during midpuberty, rather than toward the end, as adolescents experience a rapid increase

in skeletal growth.

C. Changes in the voice signal the beginning of puberty: While changes in the voice, such as voice cracking and deepening, are indeed part of puberty, they usually occur later in puberty, not necessarily at the beginning.

D. Gynecomastia commonly occurs during late puberty: Gynecomastia, the development of breast tissue in males, typically occurs during mid-puberty and may persist into late puberty but is not exclusive to that period.

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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 nurse is planning care for a 10-year-old child who will be hospitalized for an extended period of time. Which of the following actions should the nurse include in the plan of care to meet the client's psychosocial needs according to Erikson?

Correct Answer is B

Explanation

A nurse is developing a health program for the parents of school-age boys. Which of the following information about pubescent changes should the nurse include in the program?

Correct Answer is A

Explanation

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