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. Pulse rate is increased.

While there may be variations in pulse rate due to factors such as activity level and emotional state, a significant increase in pulse rate would not be a typical finding during an annual check- up for an 8-year-old child.

B. Breathing is diaphragmatic.

As children grow older, their respiratory patterns mature, and they develop diaphragmatic breathing, which is deeper and more efficient than the shallow breathing observed in infants. This change would be expected as the child gets older.

C. Secondary sex characteristics are present.

The development of secondary sex characteristics typically occurs during puberty, which begins around the ages of 9 to 13 in girls and 10 to 14 in boys. At 8 years old, it would be unlikely for significant secondary sex characteristics to be present.

D. Blood pressure has reached adult level.

Blood pressure in children gradually increases with age, but it does not reach adult levels until adolescence. At 8 years old, the child's blood pressure would still be within the pediatric range and would not resemble adult levels.

A. Tell the child that another child the same age wasn't afraid. B. Permit the child to sit on the parent's lap during the examination. C. Offer immediate praise for holding still or doing what was asked. D. Allow the child to touch and hold the equipment when possible.

Correct Answer is A

Explanation

A. Tell the child that another child the same age wasn't afraiD. This approach may backfire as toddlers may not fully understand or relate to the concept of comparison with other children. Additionally, it could potentially increase the child's anxiety by implying that being afraid is abnormal.

B. Permit the child to sit on the parent's lap during the examination: Allowing the child to stay close to their caregiver can provide comfort and security, promoting cooperation during the examination.

C. Offer immediate praise for holding still or doing what was askeD. Positive reinforcement can encourage desired behavior and cooperation by reinforcing the child's efforts to comply with the examination process.

D. Allow the child to touch and hold the equipment when possiblE. Giving the child a sense of control and familiarity with the examination tools can help alleviate fear and increase cooperation during the examination.

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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

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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