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. Body weight: Body weight is the most reliable indicator of fluid loss, as changes in weight directly reflect changes in fluid balance. Monitoring weight is essential for assessing dehydration and guiding fluid replacement therapy.
B. Skin integrity: While changes in skin turgor and skin integrity can be indicators of
dehydration, they are less reliable in infants, especially if they have certain skin conditions or are very young.
C. Respiratory ratE. Although increased respiratory rate can occur as a compensatory mechanism for metabolic acidosis associated with dehydration, it is not as reliable as changes in body weight for assessing fluid loss.
D. Blood pressurE. While blood pressure may be affected by severe dehydration, it is not as sensitive or practical as monitoring body weight for assessing fluid loss in infants.
Correct Answer is C
Explanation
A. Carotid artery: The carotid artery is not typically used to assess heart rate in infants due to its location and difficulty in palpation.
B. Radial artery: The radial artery is not typically used to assess heart rate in infants, especially in non-cooperative or newborn infants.
C. Apex of the heart: Assessing the heart rate by auscultating the apex of the heart with a stethoscope is the most accurate method for infants.
D. Brachial artery: The brachial artery is not typically used to assess heart rate in infants. It is commonly used to measure blood pressure.
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