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 ["B","C","D","E"]
Explanation
A. Seal nonwashable items in a plastic bag for 5 days:
Lice cannot survive for an extended period without a host. While sealing items in a plastic bag may trap lice, it is not a recommended or practical preventive measure.
B. Machine wash all washable items in hot water and dry in a hot dryer for at least 20 minutes:
Washing and drying bed linens, clothing, and other washable items in hot water and a hot dryer help kill lice and their eggs.
C. Vacuum carpets, car seats, mattresses, and furniture:
Vacuuming helps remove any stray lice or eggs that may have fallen onto surfaces.
D. Discourage sharing of personal items:
Avoiding the sharing of personal items, such as combs, brushes, hats, and headphones, helps prevent the spread of lice.
E. Boil combs/brushes/hair accessories for 10 minutes or soak in a lice-killing product for 1 hour:
Boiling or using a lice-killing product helps ensure that combs, brushes, and hair accessories are free from lice.
Correct Answer is A
Explanation
A. Preventing spread of infection:
This is the highest priority goal because individuals with acquired immunodeficiency syndrome (AIDS) have a severely compromised immune system, making them more susceptible to infections. Preventing the spread of infection is crucial not only for the individual's well-being but also to reduce the risk of transmitting the virus to others.
B. Maintaining skin integrity:
Skin integrity is important, but it may not be the highest priority compared to preventing the spread of infection. Skin breakdown can occur in individuals with compromised immune systems, making them more susceptible to infections, but direct measures to prevent infection take precedence.
C. Improving nutrition:
Nutrition is vital for overall health, including immune function. However, in the context of AIDS, preventing the spread of infection is considered a higher priority. Nutritional support is important but may be addressed concurrently with other goals.
D. Promoting comfort:
Comfort is an important aspect of care, but it may not be the highest priority when compared to preventing the spread of infection. Comfort measures can be integrated into the overall care plan, but infection prevention takes precedence due to the immunocompromised state of the individual.
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