The nurse is examining a 10-month-old boy who was born 10 weeks early. Which finding is cause for concern?

The child exhibits plantar grasp reflex.

The child has doubled his birth weight.

No primary teeth have erupted yet.

The child's head circumference is 49.53 cm.

Answer and Explanation

The Correct Answer is C

A. The child exhibits plantar grasp reflex: The presence of the plantar grasp reflex at 10 months

is appropriate and not cause for concern. This reflex typically diminishes by around 9 months but can persist slightly longer in premature infants.

B. The child has doubled his birth weight: Doubling birth weight by around 6 months is a normal developmental milestone, and achieving this by 10 months is appropriate, indicating healthy growth.

C. No primary teeth have erupted yet: The absence of primary teeth by 10 months, especially in a preterm infant, may indicate a delay in dental development and should prompt further evaluation by a healthcare provider.

D. The child's head circumference is 49.53 cm: The head circumference of 49.53 cm falls within the typical range for a 10-month-old infant and is not inherently concerning.

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Correct Answer is B

Explanation

A. The heart triples in size over the first year of lifE. While cardiac growth occurs during infancy, the described change is not specific to a developmental milestone.

B. Most infants triple their birth weight by 4 to 6 months of age and quadruple their birth weight by the time they are 1 year olD. This statement accurately describes a significant developmental milestone related to physical growth during infancy.

C. By 6 months of age, the infant's brain weighs half that of the adult brain; at age 12 months, the brain weighs 2.5 times what it did at birth: This statement describes brain growth rather than a

milestone related to physical growth or development.

D. The head circumference increases rapidly during the first 6 months: the average increase is about 1 in per month: While head circumference growth is important, it does not specifically relate to the described developmental milestone of weight gain during infancy.

A. Increased intracranial pressure B. Dehydration C. Overhydration D. These are normal findings

Correct Answer is D

Explanation

A. Increased intracranial pressurE. Pulsation and bulging of the fontanel may be signs of

increased intracranial pressure in infants. However, it is important to differentiate between normal fontanel characteristics and abnormal signs of elevated intracranial pressure. In this case, the pulsation and bulging are likely normal responses to crying and changes in intracranial pressure during the newborn period.

B. Dehydration: Dehydration typically presents with sunken fontanels rather than pulsation and bulging. Dehydration is a serious condition that requires prompt assessment and intervention, but it is not indicated by the findings described in the scenario.

C. Overhydration: Overhydration is not typically associated with pulsation and bulging of the fontanel. Overhydration may lead to fluid overload and edema but does not directly affect fontanel characteristics.

D. These are normal findings: Pulsation and brief bulging of the fontanel in response to crying are considered normal findings in newborns. Fontanels allow for the flexibility of the skull bones during childbirth and provide space for brain growth during infancy. Pulsation and bulging may occur temporarily during crying or changes in intracranial pressure and are not necessarily

indicative of pathology.

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The nurse is examining a 10-month-old boy who was born 10 weeks early. Which finding is cause for concern?

Nursing Test Bank

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