The nurse is performing a physical assessment on a 6-month-old baby. Which finding should the nurse understand as abnormal for this child?
The child has the beginning signs of tooth eruption.
The child is able to track and follow objects.
The child’s anterior fontanel is open.
The child’s posterior fontanel is open.
The Correct Answer is D
A. The child has the beginning signs of tooth eruption:
Teething usually begins around 4-7 months of age, so the beginning signs of tooth eruption (teething) are typical at six months.
B. The child is able to track and follow objects:
By six months, most infants can track and follow objects with their eyes, which is a normal developmental milestone for this age.
C. The child’s anterior fontanel is open:
The anterior fontanelle, the soft spot at the top of the baby's head, remains open until around 18-24 months of age, so its presence at six months is expected and considered normal.
D. The child’s posterior fontanel is open.
By six months of age, the posterior fontanelle, the soft spot located at the back of the baby's head, typically closes or is significantly smaller than it was at birth. The posterior fontanelle usually closes between 2 to 4 months of age in most infants. If it remains noticeably open by six months, it might warrant further evaluation as it could be indicative of a developmental or medical issue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Epiglottitis:
Epiglottitis is an inflammation of the epiglottis, which can result in rapid onset of symptoms such as severe sore throat, high fever, and difficulty breathing. The characteristic position described, with the child preferring to sit up, lean forward, and keep the mouth open, is known as the "tripod position." This is a protective mechanism to maintain a patent airway.
B. Mild asthma:
Asthma is a chronic respiratory condition characterized by recurrent episodes of wheezing, coughing, and shortness of breath. However, the scenario does not describe typical asthma symptoms, and the child's preference for sitting up and leaning forward is more indicative of an airway obstruction.
C. Spasmodic laryngitis:
Spasmodic laryngitis is characterized by sudden episodes of severe respiratory distress, a barking cough, and sometimes stridor. It often occurs at night and is usually not associated with high fever. The child's behavior in the scenario, particularly the preference for sitting up and leaning forward, is not a common feature of spasmodic laryngitis.
D. Acute laryngotracheobronchitis:
Acute laryngotracheobronchitis, or croup, typically presents with a barking cough, stridor, and respiratory distress. It does not usually cause the preference for sitting up and leaning forward as described in the scenario. Croup is more commonly associated with a distinctive cough sound.
Correct Answer is ["0.1696"]
Explanation
To calculate the ordered dose by the physician in mg/kg/dose, we need to convert the infant's weight from pounds and ounces to kilograms. One pound is equal to 0.4536 kg and one ounce is equal to 0.02835 kg. Therefore, the infant's weight in kilograms is:
6 x 0.4536 + 3 x 0.02835 = 2.948 kg
The ordered dose by the physician is 0.5 mg IV q 2 hours prn. To find the dose in mg/kg/dose, we divide the dose in mg by the weight in kg:
0.5 / 2.948 = 0.1696 mg/kg/dose
The recommended dosage for a child is 0.1-0.2 mg/kg/dose q2-4 hours prn. The ordered dose by the physician falls within this range, so it is a safe dosage for the infant.
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