A nurse is planning care for an infant with a bulging fontanel noted during an assessment. Which of the following actions should the nurse complete?

A. A bruit over the thyroid may indicate increased blood flow, which can occur in conditions such as Graves’ disease or hyperthyroidism. Auscultation is an important part of the assessment for clients with an enlarged thyroid to identify potential vascular abnormalities.

B. The thyroid is usually assessed with the client sitting upright with the neck slightly extended, as this position allows better visualization and palpation of the gland. Lying flat can make palpation more difficult and less accurate.

C. During thyroid palpation, the nurse typically asks the client to swallow, as swallowing elevates the thyroid and makes it easier to assess for size, nodules, or tenderness. Holding the breath is not part of standard thyroid assessment.

D. Percussion is not a standard method for assessing the thyroid. Palpation and auscultation are the primary assessment techniques. Percussion does not provide useful information about thyroid size, consistency, or vascularity.

A. Dull, throbbing facial pain is most commonly associated with sinusitis, which involves inflammation and pressure within the sinus cavities. While rhinorrhea can accompany sinusitis, pain is not the defining feature of rhinorrhea. The primary symptom of rhinorrhea is nasal discharge, not facial pressure or pain.

B. Difficulty swallowing refers to dysphagia, which involves problems with the throat or esophagus. Although allergies can cause postnasal drip that may irritate the throat, rhinorrhea specifically refers to nasal drainage. This statement focuses on swallowing difficulty rather than nasal discharge.

C. Clear, watery nasal drainage is the classic presentation of rhinorrhea. This description directly matches the definition of the condition. Clients with rhinorrhea often report frequent nose blowing due to continuous drainage.

D. Nosebleeds are known as epistaxis, which involves bleeding from the nasal mucosa. While both rhinorrhea and epistaxis involve the nose, they are distinct conditions with different causes and management.