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 D
Explanation
Choice A reason: This is not a statement that shows an understanding of safety. A fluffy pillow can pose a suffocation risk for a 10-month old baby, who may not be able to move their head away from it. The nurse should educate the parent on the safe sleep practices for infants, such as placing the baby on their back, using a firm and flat surface, and avoiding soft bedding and toys in the crib.
Choice B reason: This is not a statement that shows an understanding of safety. A car seat on the table can be unstable and fall off, causing injury to the baby. The nurse should instruct the parent on the proper use and installation of the car seat, such as securing it in the back seat of the car, facing the rear, and using the harness straps and clips correctly.
Choice C reason: This is not a statement that shows an understanding of safety. Whole milk is not recommended for a 10-month old baby, who may not be able to digest it well and may develop an allergy or intolerance. The nurse should advise the parent on the appropriate nutrition for infants, such as breastfeeding or formula feeding until 12 months, and introducing solid foods gradually and with caution.
Choice D reason: This is the best answer. A crib mattress in the low position is safer for a 10-month old baby, who may be able to pull themselves up and try to climb out of the crib. The nurse should commend the parent on this action and remind them to check the crib for any hazards, such as loose screws, gaps, or sharp edges.
Correct Answer is D
Explanation
Choice A reason: Johnson's Behavioral Systems Model focuses on how the client's behavior affects their health and well-being. It does not provide specific suggestions for enhancing caring moments.
Choice B reason: Peplau's Theory of Interpersonal Relationships emphasizes the importance of the nurse-client relationship and the role of the nurse as a counselor, teacher, and leader. It does not offer ten suggestions for maximizing caring moments.
Choice C reason: Nightingale's Environmental Theory states that the nurse's role is to manipulate the environment to promote the client's health and recovery. It does not address the concept of caring moments.
Choice D reason: Watson's Theory of Human Caring proposes that caring is the essence of nursing and that the nurse should create a caring relationship with the client. It offers ten carative factors or suggestions for maximizing caring moments, such as practicing loving-kindness, being present, cultivating spiritual practices, and creating a healing environment.
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