As the nurse conducts an assessment on a newborn infant, what finding will the nurse anticipate?
Closed fontanels
Lanugo
Fine motor control
Six to eight teeth
The Correct Answer is B
Choice A reason: This is not a finding that the nurse will anticipate. Closed fontanels are the absence of soft spots on the skull where the bones have not yet fused together. They are abnormal and unexpected in newborn infants, as they indicate a premature closure of the skull bones, which can affect the brain development and growth. The nurse should assess the presence, size, shape, and tension of the fontanels, and report any abnormalities to the physician.
Choice B reason: This is the best answer. Lanugo is a fine, soft hair that covers the body of the fetus in the womb. It helps to keep the fetus warm and hold the vernix caseosa on the skin. Lanugo is normal and expected in newborn infants, especially those born before 40 weeks of gestation. The nurse should observe the amount and distribution of lanugo, and expect it to be shed within the first few weeks of life.
Choice C reason: This is not a finding that the nurse will anticipate. Fine motor control is the ability to coordinate the movements of the small muscles of the hands and fingers. It is not well developed in newborn infants, as they have not yet acquired the skills and coordination to manipulate objects or perform complex tasks. The nurse should assess the grasp reflex and the spontaneous movements of the hands and fingers, and expect them to improve over time.
Choice D reason: This is not a finding that the nurse will anticipate. Six to eight teeth are the number of teeth that usually erupt in infants between 6 and 12 months of age. They are not present in newborn infants, as they have not yet developed the teeth buds or the ability to chew solid foods. The nurse should inspect the gums and the oral cavity, and educate the parents on the oral hygiene and feeding practices for infants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is not the statement that the nurse should prioritize. The adolescent may be experiencing a crush or a rejection, which are common and normal feelings for their age. The nurse should listen and empathize with the adolescent, but also reassure them that there are other people who like and care for them, and that their self-worth is not dependent on one person's opinion.
Choice B reason: This is the statement that the nurse should prioritize. The adolescent may be suffering from an eating disorder or a body image disturbance, which are serious and potentially life-threatening conditions. The nurse should assess the adolescent's weight, height, vital signs, and nutritional intake, and refer them to a specialist if needed. The nurse should also educate the adolescent on the dangers of skipping meals, the benefits of a balanced diet, and the importance of self-acceptance and self-esteem.
Choice C reason: This is not the statement that the nurse should prioritize. The adolescent may be facing a peer pressure or a bullying situation, which are common and challenging issues for their age. The nurse should support and encourage the adolescent to pursue their interests and hobbies, and to stand up for themselves and others. The nurse should also help the adolescent to develop coping skills, such as assertiveness, problem-solving, and stress management.
Choice D reason: This is not the statement that the nurse should prioritize. The adolescent may be experiencing a role conflict or a career dilemma, which are common and normal dilemmas for their age. The nurse should respect and acknowledge the adolescent's preferences and aspirations, and help them to explore their options and potentials. The nurse should also facilitate a communication and understanding between the adolescent and their parent, and help them to reach a compromise or a solution.
Correct Answer is D
Explanation
Choice A reason: This is not the least likely factor. The ideal self is the person that the client wants to be or thinks they should be. It reflects the client's goals, aspirations, and values. A healthy self-concept is achieved when the ideal self is congruent with the real self, which is the person that the client actually is.
Choice B reason: This is not the least likely factor. A client's self-esteem is the degree to which the client values and respects themselves. It affects the client's confidence, satisfaction, and happiness. A healthy self-concept is associated with a high self-esteem, which means that the client accepts and appreciates themselves.
Choice C reason: This is not the least likely factor. The self-image of the client is the way that the client perceives and describes themselves. It includes the client's physical, psychological, social, and spiritual attributes. A healthy self-concept is related to a positive self-image, which means that the client has a realistic and favorable view of themselves.
Choice D reason: This is the best answer. Feelings of gender dysphoria are the distress and discomfort that some people experience when their gender identity does not match their assigned sex at birth. It is not a factor that influences the self-concept, according to Rogers' theory. However, it may affect the client's self-esteem, self-image, and ideal self, and require professional support and intervention.
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