A nurse is teaching a newly licensed nurse about performing head and neck assessments of children. Which of the following statements made by the newly licensed nurse demonstrates an understanding of the teaching?
"Infants should be able to hold their head steady without support by 3 months of age."
"The posterior fontanelles close by month of age."
"An infant's lymph nodes may be large and tender at 2 months of age."
The anterior fontanelles close from 12 to 24 months of age."
The Correct Answer is D
A. Infants typically achieve head control around 4 months of age, not 3 months.
B. The posterior fontanelle usually closes by 2 to 3 months of age, not 1 month.
C. Lymph nodes in infants are usually small and non-tender, and enlarged nodes may indicate infection.
D. The anterior fontanelle generally closes between 12 and 24 months of age.
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Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}
Explanation
Heart rate: Not changed
No specific mention of heart rate changes, so it remains unchanged.
Respiratory rate: Not changed
Respirations are described as clear and shallow, with no significant change noted over time. The child's respiratory rate appears stable.
Urine output: Improved
Initially, the output was 8 mL of concentrated urine over 2 hours, and by 1600, the output increased to 30 mL of yellow urine over 2 hours. The improvement in both the volume and color indicates that hydration status is improving.
Mucous membranes: Improved
At 1000, the mucous membranes were described as pale and dry. By 1200, they were pale and sticky, which is still a sign of dehydration, but by 1600, they are likely improving as the child is receiving intravenous fluids and hydration.
Abdominal examination: Not changed
The abdominal examination remains consistent, with mild tenderness on palpation and hyperactive bowel sounds observed throughout the shift. These findings indicate that the child is still experiencing gastrointestinal upset but without significant worsening.
Vomiting frequency: Improved
Vomiting frequency decreased from 8 times in the previous 24 hours to just 1 episode in the past 2 hours, indicating a significant improvement in vomiting control.
Correct Answer is ["C","D","E"]
Explanation
A. MRSA requires contact precautions, not droplet.
B. Tuberculosis requires airborne precautions, not droplet.
C. Pertussis is transmitted via respiratory droplets.
D. Influenza is transmitted via respiratory droplets.
E. Group A Streptococcus infections, especially pharyngitis, require droplet precautions.
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