The nurse is assessing an infant during a health supervision visit. Which assessment findings are considered normal variations for this client? Select all that apply.
always breathing through the nose
a rounded chest
hearing breath sounds over the entire chest
pubertal development
knock-knees
Correct Answer : A,B,C
A. Always breathing through the nose; Infants are typically obligate nose breathers for the first several months of life, meaning they primarily breathe through their noses.
B. A rounded chest: A rounded or barrel-shaped chest is normal in infants and gradually changes as the child grows.
C. Hearing breath sounds over the entire chest; Due to the thin chest wall in infants, breath sounds are easily transmitted and heard throughout the chest.
D. Pubertal development; This is not a normal finding in infancy; it occurs later during adolescence.
E. Knock-knees; Genu valgum (knock-knees) is a normal variation in toddlers and young children (typically around ages 3–5), not infants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Regression, such as needing diapers again, is a common response in toddlers due to stress and anxiety caused by hospitalization.
B. Temper tantrums over minor issues are typical toddler behavior, not specifically linked to hospitalization.
C. Maintaining usual routines like napping is a positive behavior and not an effect of hospitalization.
D. Bargaining is more characteristic of older children; toddlers typically have limited ability to negotiate.
Correct Answer is ["A","E"]
Explanation
A. Sitting up prevents choking and promotes safe swallowing.
B. Not all medications can be mixed with food, as it may affect absorption or effectiveness; always check instructions.
C. Pediatric doses are calculated individually, sometimes exceeding adult doses based on weight or body surface area.
D. Medication should be given slowly into the side of the mouth to avoid choking or gagging, not directly into the back of the throat.
E. Offering age-appropriate choices empowers the child and can improve cooperation during medication administration.
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