The nurse is performing a physical assessment of a 3-year-old girl. What finding would be a concern for the nurse?

The toddler's anterior fontanel is not fully closed.

The toddler gained 3 in in height since last year.

The toddler gained 4 lb in weight since last year.

The circumference of the child's head increased 1 in since last year.

Answer and Explanation

The Correct Answer is A

A. The toddler's anterior fontanel is not fully closeD. The closure of the anterior fontanel typically occurs by around 18 months of age. If the fontanel is still open at 3 years old, it may indicate a delay in normal development and could be a cause for concern. The nurse should further assess this finding and consider follow-up with the healthcare provider.

B. The toddler gained 3 in in height since last year: Growth in height is expected during early childhood, and a gain of 3 inches over a year is within the normal range for a 3-year-old.

C. The toddler gained 4 lb in weight since last year: Weight gain is also expected during early childhood, and a gain of 4 pounds over a year is within the normal range for a 3-year-old.

D. The circumference of the child's head increased 1 in since last year: Head circumference typically increases during early childhood as the brain grows, and a 1-inch increase over a year is within the normal range for a 3-year-old.

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Correct Answer is B

Explanation

A. At 3 months, infants are not expected to have the fine motor skills necessary to pick up objects with their fingers.

B. By 3 months, infants should be able to lift their head and chest during tummy time, and the inability to do so could indicate developmental delays or other health issues.

C. Infants typically cannot sit without support until they are around 6 months old.

D. The ability to bring objects to the mouth develops around 4 months of age, so it is not expected for a 3-month-old infant to do this consistently.

A. "Do you participate in any sports?" B. "Do you play any instruments?" C. "Do you like to do puzzles?" D. "Do you like to construct models?"

Correct Answer is A

Explanation

A. "Do you participate in any sports?": This question directly addresses gross motor skills by inquiring about physical activities that involve large muscle groups and coordination, such as sports.

B. "Do you play any instruments?": While playing musical instruments may involve some coordination and motor skills, it primarily assesses fine motor skills rather than gross motor skills.

C. "Do you like to do puzzles?": Puzzles primarily assess cognitive skills rather than gross motor skills.

D. "Do you like to construct models?": Constructing models also primarily assesses fine motor skills and cognitive abilities rather than gross motor skills.

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The nurse is performing a physical assessment of a 3-year-old girl. What finding would be a concern for the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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