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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Appearance of pubic hair around 11 to 13 years old - Pubic hair development typically occurs around the ages of 11 to 13 in girls, signaling the onset of puberty. This is a normal part of physical development.
B. Swelling or redness of the labia minora - Swelling or redness of the labia minora may indicate inflammation or infection, unrelated to normal puberty development.
C. Lesions on the external genitalia - Lesions on the external genitalia are not normal signs of puberty and may indicate a medical issue requiring evaluation and treatment.
D. Presence of labial adhesions - Labial adhesions, where the labia minora stick together, are not directly related to puberty onset and may require medical attention if they cause discomfort or urinary issues
Correct Answer is A
Explanation
A. Puberty might be delayed if scrotal changes have not occurred by the age of 11 years: This statement is accurate because the lack of scrotal changes by the age of 11 years may indicate delayed puberty, prompting further evaluation by a healthcare provider.
B. Growth spurts in height occur toward the end of midpuberty: Growth spurts in height typically occur during midpuberty, rather than toward the end, as adolescents experience a rapid increase
in skeletal growth.
C. Changes in the voice signal the beginning of puberty: While changes in the voice, such as voice cracking and deepening, are indeed part of puberty, they usually occur later in puberty, not necessarily at the beginning.
D. Gynecomastia commonly occurs during late puberty: Gynecomastia, the development of breast tissue in males, typically occurs during mid-puberty and may persist into late puberty but is not exclusive to that period.
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