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 D
Explanation
A. Improved inflammatory response is not a typical long-term consequence of pain. Chronic pain can actually exacerbate inflammation or disrupt normal immune responses.
B. Hyposensitivity to pain; Chronic pain often leads to hypersensitivity, where the nervous system becomes more sensitive to pain stimuli, not less.
C. Increased motor performance is unlikely. Chronic pain often reduces physical activity, coordination, and function due to discomfort and protective behaviors.
D. Decreased immune system function; Persistent or chronic pain can lead to stress responses that suppress immune system activity, making the body more susceptible to illness.
Correct Answer is C
Explanation
A. At 8 weeks (about 2 months), infants typically start some head control but are not yet rolling from back to belly.
B. At 2 months, rolling over usually has not started.
C. Rolling from back to belly typically develops around 5 to 6 months of age as gross motor skills improve.
D. By 10 months, rolling is well established and infants are usually sitting, crawling, or standing.
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