A nurse is caring for a toddler who is 24 months of age during a well-child clinic visit. Which of the following is an expected finding?
Ocular strabismus
Slightly bowed legs
Thoracic breathing pattern
Anterior fontanelle less than 1 cm
The Correct Answer is B
Choice A reason: Ocular strabismus (crossed eyes) is not expected at 24 months. By this age, ocular alignment should be normal. Persistent strabismus beyond 6 months of age requires evaluation for possible vision problems.
Choice B reason: Slightly bowed legs are expected in toddlers due to normal physiologic development. This finding is common as children transition from crawling to walking and usually resolves by age 3 to 4 years. It is considered a normal variation at 24 months.
Choice C reason: Toddlers at 24 months should demonstrate an abdominal breathing pattern, not thoracic. Thoracic breathing is more characteristic of older children and adults. Therefore, this finding would not be expected.
Choice D reason: The anterior fontanelle typically closes between 12 and 18 months. At 24 months, it should already be closed. An anterior fontanelle less than 1 cm at this age would be abnormal and suggest delayed closure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Extending the legs above heart level is not appropriate for dehiscence. This position does not reduce intra-abdominal pressure or protect the incision site.
Choice B reason: Placing the client in a low-Fowler’s position with knees slightly flexed reduces tension on the abdominal incision. This position minimizes strain, prevents further separation, and promotes comfort. It is the most appropriate immediate action.
Choice C reason: The Valsalva maneuver increases intra-abdominal pressure, which would worsen dehiscence and potentially lead to evisceration. It is contraindicated.
Choice D reason: Applying a dry gauze dressing does not provide adequate protection. A sterile, moist dressing is preferred to prevent tissue drying and reduce infection risk. Dry gauze could adhere to exposed tissue and cause trauma upon removal.
Correct Answer is D
Explanation
Choice A reason: Older adults have an increased risk, not decreased risk, for atelectasis due to reduced lung elasticity, weaker respiratory muscles, and decreased cough reflex.
Choice B reason: Diaphragmatic movement decreases with age because of muscle weakening and changes in thoracic structure. Increased diaphragmatic movement is not an age-related change.
Choice C reason: Chest wall compliance decreases with age due to calcification of costal cartilage and stiffening of the thoracic cage. Increased compliance is incorrect.
Choice D reason: Decreased blood oxygenation is correct. Aging reduces alveolar surface area and capillary perfusion, leading to lower arterial oxygen levels. This physiologic change must be considered when planning activities to avoid hypoxemia and fatigue.
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