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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. TympaniC. Tympanic temperature measurement using an ear thermometer is a convenient and accurate method for assessing temperature in children, including toddlers.
B. Oral: Oral temperature measurement using a digital thermometer placed under the tongue is a commonly used method for children who can cooperate with the procedure and keep the
thermometer in their mouth.
C. Axillary: Axillary temperature measurement using a thermometer placed in the armpit is a non-invasive method suitable for children who cannot cooperate with oral or tympanic
measurements or when rectal measurement is contraindicated.
D. Rectal: Rectal temperature measurement is generally considered the most accurate method for assessing temperature in infants and young children, especially when accuracy is critical.
However, it may be less appropriate in the emergency department setting due to its invasive nature and potential discomfort for the child, especially in cases of diarrhea or vomiting where rectal temperature measurement may be difficult or impractical.
Correct Answer is B
Explanation
A. Menarche
Menarche refers to the onset of menstruation, typically occurring around 12 to 13 years of age, although it can vary widely.
B. Thelarche
Thelarche is the development of breast buds, which usually occurs around 8 to 13 years of age in girls, marking the beginning of breast development and the first sign of puberty.
C. Tanner stage 5
Tanner stage 5 refers to the final stage of sexual maturity in the Tanner Scale, characterized by adult breast development and pubic hair distribution. It is not typically used to describe the initial appearance of breast buds.
D. Puberty
Puberty is the period of development during which sexual maturity is attained, including physical changes such as growth spurts, development of secondary sexual characteristics, and
reproductive capacity. Thelarche is an early sign of puberty, but it does not encompass the entire puberty process.
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