A nurse is assessing the fontanels of an 8-month-old infant. Which of the following findings should the nurse recognize as an expected finding
The anterior fontanel is open.
Both fontanels are the same size.
The posterior fontanel is open.
Both fontanels show moulding
The Correct Answer is A
Choice A reason
The anterior fontanel is open is the correct answer. An expected finding in an 8-month-old infant is that the anterior fontanel (the soft spot on the top of the baby's head) is open. The fontanelles are spaces between the bones of an infant's skull that allow for the baby's brain to grow and the skull to mould during birth.
The anterior fontanel typically remains open until the baby is around 18 to 24 months old, with the closure process starting sometime after 9 months of age. Therefore, at 8 months of age, it is normal for the anterior fontanel to still be open.
Choice B reason:
Both fontanels are the same size is incorrect. Both fontanels are usually not the same size. The anterior fontanel is larger and diamond-shaped, while the posterior fontanel is smaller and triangular.
Choice C reason:
The posterior fontanel is open is incorrect. The posterior fontanel, located at the back of the baby's head, usually closes earlier than the anterior fontanel. It typically closes within the first few months after birth, so it is not expected to be open at 8 months of age.
Choice D reason
Both fontanels show molding is incorrect. Molding refers to the temporary shaping of the baby's head during birth due to the pressure exerted during the passage through the birth canal. By 8 months of age, the molding typically resolves, and the baby's head should have a more rounded appearance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. A client who is 1 day postoperative following a vertebroplasty. A vertebroplasty is a procedure that injects cement into a fractured vertebra to help relieve pain and stabilize the spine. The recovery time for this procedure is usually short and the complications are rare.
Therefore, this client is most likely to be stable and ready for early discharge.
Choice A is wrong because a client who is receiving heparin for deep-vein thrombosis (DVT) needs close monitoring of their blood levels and clotting factors. Heparin is a blood thinner that prevents the clots from getting bigger or breaking loose and traveling to the lungs, which can cause a life-threatening condition called pulmonary embolism (PE).
This client is not a good candidate for early discharge.
Choice C is wrong because a client who has cancer and a sealed implant for radiation therapy needs to be isolated in a special room to prevent exposure of others to radiation. A sealed implant is a small holder that contains a radioactive source that is placed inside or near the tumor to deliver high doses of radiation. This type of internal radiation therapy, also called brachytherapy, can last from several minutes to several days, depending on the type and dose of the radioactive source.
This client is not a good candidate for early discharge.
Choice D is wrong because a client who has COPD and a respiratory rate of 44/min has signs of respiratory distress and possible hypoxemia (low oxygen levels in the blood).
COP
Correct Answer is A
Explanation
The correct answer is choice A. The nurse should compare new prescriptions with the list of medications the client reports. This is part of the medication reconciliation process, which is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten.
Choice B is wrong because the nurse should not encourage the client to make his own list after he returns to his home. The nurse should provide the client with an updated and accurate list of medications before discharge and instruct the client to keep it with him at all times.
Choice C is wrong because the nurse should not include any adverse effects of the medications the client might develop. The nurse should include any known allergies or adverse reactions the client has experienced in the past, but not potential adverse effects that have not occurred.
Choice D is wrong because the nurse should not exclude nutritional supplements from the list of medications the client reports. The nurse should include all prescription medications, herbals, vitamins, nutritional supplements, over-the-counter drugs, vaccines, diagnostic and contrast agents, radioactive medications, parenteral nutrition, blood derivatives, and intravenous solutions in the medication reconciliation process.
Some of these products may interact with prescribed medications or affect laboratory results.
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