The nurse is doing a routine assessment on a 19-month-old infant and notes that the anterior fontanel is closed. This should be interpreted as:
An abnormal finding-indicates the need for developmental assessment.
A normal finding.
An abnormal finding-indicates the need for immediate referral to a practitioner
A questionable finding-the infant should be rechecked in 1 month.
The Correct Answer is B
A. An abnormal finding-indicates the need for developmental assessment.
This is not accurate. The closure of the anterior fontanel within the expected age range does not indicate an abnormal finding or the need for additional developmental assessment.
B. A normal finding.
This is the correct interpretation. The anterior fontanel normally closes between 12 to 18 months, and closure by 19 months is within the expected developmental range.
C. An abnormal finding-indicates the need for immediate referral to a practitioner.
This is not necessary based on the information provided. The closure of the anterior fontanel within the expected timeframe is a normal finding.
D. A questionable finding-the infant should be rechecked in 1 month.
There's no need for rechecking in 1 month. The closure of the anterior fontanel at 19 months is considered normal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
A. Respirations: Monitoring respiratory rate and pattern is crucial when a child is receiving narcotics, as these medications can depress the respiratory system. Rapid or shallow breathing may indicate respiratory distress.
B. Level of consciousness: This is important to assess for any signs of sedation or altered mental status, which can be a side effect of narcotics.
C. Oxygen saturations: Monitoring oxygen saturations is essential, especially if there are concerns about respiratory depression. A decrease in oxygen saturations could indicate inadequate ventilation.
D. Bowel sounds: While bowel sounds are important to assess for gastrointestinal function, they are not the top priority when monitoring a child receiving narcotics. Respiratory and central nervous system status take precedence.
Correct Answer is C
Explanation
A. Serum calcium:
- Serum calcium levels are not typically used to diagnose cystic fibrosis. Calcium levels are more related to bone health, neuromuscular function, and various metabolic processes. While electrolyte imbalances can occur in CF, serum calcium alone is not specific for its diagnosis.
B. Urine creatinine:
- Urine creatinine is not a diagnostic test for cystic fibrosis. Creatinine is a waste product produced by muscles and excreted by the kidneys. Monitoring creatinine levels is more related to assessing kidney function and is not specific to CF diagnosis.
C. Sweat chloride test:
- The sweat chloride test is considered the gold standard for diagnosing cystic fibrosis. Individuals with CF have higher than normal levels of chloride in their sweat. This test measures the amount of chloride in the sweat, and a high level is indicative of CF. It is a noninvasive and reliable diagnostic test for CF.
D. Bronchoscopy:
- Bronchoscopy is not used as a primary diagnostic test for cystic fibrosis. While it may be performed for other reasons, such as assessing airway abnormalities or obtaining samples for culture, it is not the primary method for diagnosing CF.
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